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• STATE ID NUMBER 00000039509003 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />(:C) O1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(COP.PORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />MOBIL OIL CORPORATION ( ) 01 FED ( ) 02 STATE ( 1p03 LOCAL <br />STREET ADDRESS CITY p STATE ZIP?yS L <br />Al9 SO SIQWc.+ MT D - �0 �Q 2.► � `+DNGORJ CA 4mm* ' <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />DEALER/FOREMAN/S PERVISOR <br />CONTAINER <br />MOBIL SERVICE STATION <br />B. <br />looWeeS4lL'hie0 � (� • <br />� <br />STREET ADDRESS <br />YEAR INSTALLED 1984 ( } UNKNOWN <br />NEAREST CROSS STREET <br />CONTAINER CAPACITY: 6000 GALLONS ( ) UNKNOWN <br />1469 EAST HAMMER LANE <br />CONTAINER STORE: ( <br />WEST <br />F. <br />CITY <br />01 YES ( ) 02 NO <br />( ) 05 WASTE OIL <br />COUNTY <br />( ) 02 STAINLESS STEEL (X) 03 FIBERGLASS ( ) 04 <br />t ) 07 STEEL CLAD C ) 08 BRONZE ( 1 09 COMPOSITE <br />13 OTHER: <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95207 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />1469 EAST HAMMER LANE <br />STOCKTON <br />CA <br />95207 <br />PHONE W/AP.EA CODE <br />TYPE OF BUSINESS <br />209-478-1522 <br />(X) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />4 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/ARE.A CODE <br />EN R Ola-fieg-e"i <br />/ - 3 - Lo <br />COMPTETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />CONTAINMENT: ( <br />CONTAINER <br />NUMBER 3 <br />B. <br />MANUFACTURER (IF APPROPRIATE): UNKNOWN <br />YEAR MFG: 1984 <br />C. <br />YEAR INSTALLED 1984 ( } UNKNOWN <br />D. <br />CONTAINER CAPACITY: 6000 GALLONS ( ) UNKNOWN <br />JE. DOES THE <br />CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINS TORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />(' ) 01 UNLEADED ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL <br />01 YES ( ) 02 NO <br />( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: ( <br />) GAUGE ( ) INCHES ( <br />) CM (X) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) <br />(X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( ) <br />03 LINED <br />D. <br />( ) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL <br />06 ALUMINUM <br />UNKNOWN ( ) <br />( ) 02 STAINLESS STEEL (X) 03 FIBERGLASS ( ) 04 <br />t ) 07 STEEL CLAD C ) 08 BRONZE ( 1 09 COMPOSITE <br />13 OTHER: <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />