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STATE ID NUMBER 00000018549003 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />01 NEW PERMIT ( ) 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 />4AME(COPFOPA.TION.INDZVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />_INCOLN VILLAGE WEST MARINE LT ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />:TP.EET ADDRESS CITY STATET95209 <br />)649 EMBARCADERO DR STOCKTON CA <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />DE.ALEP/FOP.EMAN/SUPERVISOR <br />VILLAGE WEST MARINA <br />NUMBER 3 <br />WILLIAM LADD <br />STREET A.DOP.ESS <br />YEAR MFG: <br />NEAREST CROSS STREET <br />6649 EMBARCADERO DR <br />D. <br />BEN HOLT <br />CITY <br />E. DOES THE CONTAINER STORE: ( <br />COUNTY <br />ZIP <br />STOCKTON <br />FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />PREMIUM (X) 04 DIESEL ( ) 05 WASTE OIL f <br />SAN JOAgUIN <br />95209 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />6649 EMBARCADERO OR <br />STOCKTON <br />CA <br />95209 <br />PHCNE W.IAPEA CCDE <br />TYPE OF BUSINESS <br />209-951-1551 <br />(X) 01 GASOLINE STATION ( l 02 OTHER <br />NUMB= -P. OF CONTAINERS <br />PUPAL AREAS ONLY : <br />TOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />)AYS: NAME(L.AST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST).AND PHONE W/AP.E.A 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 />) CM (X) UNKNOWN <br />CONTAINER <br />NUMBER 3 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. <br />YEAR INSTALLED 1972 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 5000 GALLONS ( <br />) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE <br />( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 <br />FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />PREMIUM (X) 04 DIESEL ( ) 05 WASTE OIL f <br />IF YES CHECK APPROPRIATE BOX(ES): <br />) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />) 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 />( 1 01 <br />DOUBLE WALLED ( <br />) 02 SINGLE WALLED ( ) 03 LINED <br />D. <br />( 1 01 <br />( ) <br />(X) 12 <br />CARBON STEEL ( <br />06 ALUMINUM ( ) <br />UNKNOWN ( ) 13 <br />) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 <br />07 STEEL CLAD ( 108 BRONZE ( ) 09 COMPOSITE <br />OTHER: <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( l 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />