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STATE ID NUMBER 00000018549002 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />( 01 NEW PERMIT ( l 05 RENEWED PERMIT ( l 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />14ME(COPPOPAT:ON,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />_INCOLN VILLAGE WEST MARINE LT ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />;TP.EET ADDRESS CITY STATE ZIP <br />X649 EMBARCADERO DR STOCKTON CA 95209 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER <br />DEALER/FOREM.AN/SUPERVISOR <br />CONTAINER <br />VILLAGE WEST MARINA <br />B. <br />WILLIAM LADD <br />YEAR MFG:Tc_-YEAR <br />STREET ADDRESS <br />INSTALLED 1972 ( l UNKNOWN <br />NEAREST CROSS STREET <br />CONTAINER CAPACITY: 10000 GALLONS f ) UNKNOWN <br />6649 EMBARCADERO DR <br />) 01 WASTE (X) 02 PRODUCT <br />BEN HOLT <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL <br />CITY <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />COUNTY <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 '.4/.APER CODE <br />TYPE OF BUSINESS <br />209-951-1551 <br />(X) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLYTOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />i.AYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: N.AME(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 />l CM (X) UNKNOWN <br />CONTAINER <br />NUMBER 2 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG:Tc_-YEAR <br />C. <br />INSTALLED 1972 ( l UNKNOWN <br />D. <br />CONTAINER CAPACITY: 10000 GALLONS f ) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />l CM (X) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( l 01 <br />DOUBLE WALLED ( <br />l 02 SINGLE WALLED ( l 03 LINED <br />D. <br />( ) 01 <br />( ) <br />(X) 12 <br />CARBON STEEL ( <br />06 ALUMINUM ( ) <br />UNKNOWN ( ) 13 <br />) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 <br />07 STEEL CLAD t ) 08 BRONZE ( l 09 COMPOSITE <br />OTHER: <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />