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• • STATE ID NUMBER 00000044353001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> ( l 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT f 1 OB MINOR CHANGE (NO SURCHARGE)) 09 DELETE FROM FILE (NO FEE) <br /> I OWNER <br /> NAME(COP.PORATION.INDIVIOUAL OR PUBLIC AGENCY] <br /> W.V. RAYMOND PUBLIC AGENCY ONLY <br /> ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS <br /> 817 S. CENTER ST. CITY STATE ZIP <br /> STOCKTON CA 95206 <br /> II FACILITY <br /> FACILITY NAME <br /> PROPERTY HELD FOR RENTAL DEALER/FOREMAN/SUPERVISOR <br /> STREET ADDRESS <br /> 812 MOFFAT BLVD. NEAREST CROSS STREET <br /> ROSELAWN <br /> CITY <br /> COUNTY ZIP <br /> MANTECA SAN JOAQUIN 95336 <br /> MAILING ADDRESS <br /> P.O. BOX 567 CITY STATE ZIP <br /> STOCKTON CA 95201 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-466-8604 ( ) 01 GASOLINE STATION (X) 02 OTHER <br /> NUMBER OF CONTAINERS AURAL AREAS ONLY : TOWNSHIP RANGE <br /> 1 SECTION <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/AREA CODE <br /> RAYMOND, W.V. 209-466-8604 RAYMOND W.V. <br /> 209-951-7792 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> FA. (X) 01 TANKE(IF <br /> OTHER: CONTAINER NUMBER #1 <br /> FACTURERPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 500 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (X) 02 REGULAR ( l 03 PREMIUM ( 1 04 DIESEL [ 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> D <br /> A. THICKNESS OF PRIMARY CONTAINMENY f ) GAUGE ( 1 INCHES f ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. f l 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> f ) 06 ALUMINUM ( ) 07 STEEL CLAD C ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> � (X) 12 UNKNOWN ( ) 13 OTHER: <br /> ISC04-070185 (10/18/85) <br /> PAGE 1 <br />