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Y. <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND..STQRAGE:;,,T_AJ1NK • .;_ -, <br /> 01 NEN PERMIT ( '1 06 REHENEO PERMIT ( .1'07 TAM:CLOSEO 6 1;99 OELETC fRON FILE (NO FEE <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 06 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMEICOPPORATtON.INOIVIOVAI OR PUOLIC AGENCY) PUBLIC AGENCY ONLY - <br /> V/+IJ A�I//v/7/ FEO l 1 02 STATE ,lis) OT:LOCAL <br /> • STREET ACORESS :t3 CITY - STATE- IIP <br /> II FACILITY <br /> FACILITY NAME DEALEVFOREMCN/SUPERVISOR <br /> e z 914 vc VAry u v m r{ <br /> STREET ADD-ESS NEAREST CROSS TPECT <br /> .22 <br /> sr <br /> CITY COUNTY I P <br /> .SAN Q/o K 7/✓ <br /> MAILING ADDRESS CITY STATE LIP, <br /> SAIk.e S S-ni 9i 206 <br /> PHONE W•APCA CDOC TYPE OF PUf INCSf <br /> O 6' � ( 1 01 GASOLINE STATION LV <br /> _02 OTHER <br /> N USER CP CONTAINERS RURAL AR[Af ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM[)LAST NAME FIPST) AND PHONE W/AREA CODE NIONTf: NAMCCLAST NAME FIRST) AND PHONE W/ARIA CODE <br /> rl COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> kF A. (�1 01 TANK ( 1 02 OTHER: CONTAINER NUMBER 7' <br /> S. MANUFACTURER (IF APPROPRIATE): )f Vii. — .YEAR MFG: C. YEAR INSTALLED 1'i�� %( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS f 1 UNICNOMH E. DOES THE CONTAINER STORE: 1 1 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BO%(ES1: <br /> S O1 101LEADED 1 1 02 REGULAR 1 1 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL 1 1 06 OTHER__ <br /> V CONTAINER CONSTRUCTION <br /> II4rA. THICKNESS OF PRIMARY CONTAINMENT: <br /> ( 1 GAUGE 1 1 INCHES 1 1_CM _ \ UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) '1 1 02 NON-VAULTED 1,A 03 UNKNOWN <br /> IC. 1 1 01 0O5LE WILLED 1 1 02 SI14GLE WALLED 1 1 03 LINED <br /> D. l 1 01 CARBON STEEL 1 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 1 00 BRONZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1X1 12 UIIKNOW14 l 1 13 OTHER: <br /> IIiC 04-0 7 0185 _---- --- -- _�-_- --�--- PAGE 1 <br />