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STATE ID NUMBER 00000016549001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />(>�01 NEW PERMIT ( l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />JAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />.INCOLN VILLAGE WEST MARINE LT ( ) 01 FED ( ) 02 STATE [ ) 03 LOCAL <br />>TREET ADDRESS CITY STATE ZIP <br />1649 EMBARCADERO DR STOCKTON CA 95209 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />DEALER/FOREMAN/SUPERVISOR <br />CONTAINER <br />VILLAGE WEST MARINA <br />B. <br />WILLIAM LADD <br />YEAR MFG <br />STREET ADDRESS <br />YEAR. INSTALLED 1972 ( ) UNKNOWN <br />NEAREST CROSS STREET <br />CONTAINER CAPACITY: 10000 GALLONS ( ) UNKNOWN <br />6649 EMBARCADERO DR <br />CONTAINER STORE: ( <br />BEN HOLT <br />F. <br />CITY <br />01 YES ( ) 02 NO <br />( ) 05 WASTE OIL ( <br />COUNTY <br />) 03 FIBERGLASS t l 04 <br />BRONZE ( ) 09 COMPOSITE <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95209 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />6649 EMBARCADERO OR <br />STOCKTON <br />CA <br />95209 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />209-951-1551 <br />(X) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />MANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />)AYS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />,ADD, BILL 209-951-1551 LADD, BILL 209-368-8218 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />( ) GAUGE ( ) INCHES ( <br />CONTAINER <br />NUMBER 1 <br />B. <br />MANUFACTURER. (IF APPROPRIATE): <br />YEAR MFG <br />C. <br />YEAR. INSTALLED 1972 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 10000 GALLONS ( ) UNKNOWN <br />JE. DOES THE <br />CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />( ) 01 UNLEADED (X) 02 REGULAR t ) 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 />IA. <br />THICKNESS OF PRIMARY CONTAINMENT: <br />( ) GAUGE ( ) INCHES ( <br />) CM (X) UNKNOWN <br />B. <br />f ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />l 03 UNKNOWN <br />C. <br />( l 01 <br />DOUBLE WALLED ( <br />) 02 SINGLE WALLED ( <br />103 LINED <br />D. <br />( ) 01 <br />t ) <br />(X) 12 <br />CARBON STEEL f <br />06 ALUMINUM ( ) <br />UNKNOWN ( ) 13 <br />l 02 STAINLESS STEEL ( <br />07 STEEL CLAD ( ) 08 <br />OTHER: <br />) 03 FIBERGLASS t l 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />