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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (yl <br /> 01 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED -- ( ) 09 DELETE FROM FILE (NO FEE) 1 <br /> T!"7 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 09 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAM.E!COevCP<T20N, NOIVIDU<L OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> J i 7]—_ l 1 01 FED 1 1 02 STATE f 1 03 LOCAL <br /> CITY STATE ZIP <br /> L <br /> II FACILITY <br /> 'n.'VACILITY VME DEALER/FOPEI EN/SUPERVISOR <br /> Aw <br /> � . <br /> STREET <CC'ES NEAPEST CROSS STREET <br /> �_���� <br /> 'C:TYl_j� , COUNTY ZIP <br /> MAILING ADDOPESS CITY STATE ZIP <br /> CA <br /> L / <br /> .PHONE W'ACEA CODE BUSINESS �y� <br /> l 1 <br /> 01 GASOLINE STATION IXL 02 OTHER <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY TOWNSHIP PANGS SFCiION <br /> III 2// HOUR EMERGENCY CONTACT PERSON <br /> OA NA ME!LAST NAM F FIPSTI AND PHONE W/APG CODE NIGHTS: HAMF(IAST NAME FZRSTi AND PNO NE WIAAEA CODE <br /> �7 - - � <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. a 01 TAt;K f 1 02 OTHER CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED/f/-n 1 1 UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS l 1 UNKNOWN E. DOES THE CONTAINER STORE ( I O1 HASTE l .l 02 PRODUCT <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? jy.LO1 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOXIEST <br /> 1 1 01 UNLEADED ( 102 REGULAR 1 ) 03 PREMIUM 104 DIESEL 1 105 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES ( 1 CM UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN LRIDERGROUHD VAULT) ( Ln2 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. ! 1 01 DOUBLE WILLED ()6.02 SINGLE WALLED 1 103 LINED <br /> D. CARBON STEEL l 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 ) 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD ( 1 OB BROtIZE l ) 09 COMPOSITE ( 1 30 NON-METALLIC <br /> l 1 12 UNKNOWN ( 1 13 OTHER: <br /> PAGE L <br />