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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 09 DELETE FROM FILE (NO FEE) <br /> J�O1 NEW PERMIT f ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> ( 7 <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER _ <br /> PUBLIC AGENCY ONLY <br /> NAME( OPP RATION.I IVIDU�-OP PUBLIC AG26 <br /> ENCY) ( 7 01 FED ( ) 02 STATE 03 LOCAL <br /> ` CITr STATE ZIP S <br /> STREET ADD ESS S�. '�r� L/�} <br /> II FACILITY <br /> FA L TY NAME DEA R/FOREMAN/SUPERVISOR <br /> NEAR T CROSS STREET <br /> STREET DDRESS _ ail <br /> , COUN <br /> QQ <br /> CITI� ` Q / CITY 310- <br /> ( STATE <br /> Z�S <br /> MAILING ADO ESS �7 �� r0.(. Q/ 2IP <br /> 1 ramLi9'53 <br /> PHONE W/APEA CODE TYPE OF BUSINESS �1•PG !' .Ll� <br /> ( ) 01 GASOLINE STATION (jQ 02 OTHER <br /> ` <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 17�sUafd er ;;L9 .was- 9 ?-/e 5 SCJ 9-8 3S- 9 /rte <br /> F COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (�1 TANK f 7 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED S( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS ( ] UHKNOLDJ E. DOES THE CONTAINER STORE: ( ) 01 WASTE A<r 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL YES 1 ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED 1 ) 02 REGULAR ( ) 03 PREMIUM PO 04 DIESEL ( ) 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( ) INCHES ( ) CM f _UHOWN <br /> � NK <br /> B. l ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) _Qd.02 MON-VAULTED ( ) 03 UNKNOWN <br /> C. ( > 01 DOUBLE WALLED UId 2 SINGLE WALLED t 1 03 LINED <br /> L CHLORIDE <br /> D. f 01 CABON <br /> 06R <br /> RALUMITNUML 111)072STEELNCLAD STEEL <br /> 08( 03 BRONZEFIBERG09SS 04 COMPOSITE �(L1v10r14ON-METALLIC( ) 05 CONCRETE <br /> 06 2 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />