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STATE ID NLRIBER <br /> CLOSED ( 1 09 DELETC FROM FILE (NO FEE) <br /> OPERATE NDERGROUND <br /> APPLICATION FOR PERMIT TO STORAGE TANK - <br /> TANK <br /> 1 1 l 1 OS RENEWED PERMIT 1 1 OD MINOR_CHANGE <br /> NEW PERMIT IND SURCHARGE- <br /> 06 AMENDED PERMIT <br /> y0� CONDITIONAL PERMIT_ <br /> 1 1 <br /> OWNER ___— -- -- PUBLIC AGENCY ONLY — <br /> NAMT( ( 1 01 FED 1 1 02 STATE OS LOCAL <br /> l 1 <br /> -.—- PP /ATION.T IV DUAL OR CVDLIC AOEH� <br /> C�^O STAT! I <br /> ctrr <br /> II FACILITY \ <br /> Of AIfR/f OPlMEN�SVPEPVISf? OOLkl <br /> FACILITY NAME — CJ A�� 'I 'IMMLY(�-7 <br /> RI NEA/EST C/ SS STPILT <br /> SiPC[T AOC'f SL g Q I p ANYa/1Y� G <br /> w l I I�y <br /> _._�� COU TY P/LI <br /> CITY I — <br /> I✓iV.�i✓ <br /> CITY <br /> MAILING AO f S <br /> -- ` o TYPE OF BUSINESS <br /> PHONE W'A.! CODE Q Ixj O1 GASOLINE STATION 1 1 02 OTHER <br /> ;Lo 33 �^(J� _ SECTION <br /> -+ RANGE <br /> PUPAL APEAS ONL ' SHIP <br /> Y TOY <br /> NUI'DE. Cl CONTAINlPS r� — <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: MAY,C(IAST NAMC /I►STI AND PHONE 1 A/CA COO[ NIGHTS: NAM (LAST N ME FIRST) ND P ONE W/AREA C 8 <br /> - o� as-10:V e o ewrl <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. J)J Qt`TANK I 1 02 OTHER: CONTAINER MR18ER <br /> B. MANUFACTURER IIF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED // �z l 1 UNKNO-01 <br /> 0. CONTAINER CAPACITY: G - GALLONS_ S . llN1(NONN E. GOES TME CONTAINER STORE: ( 1 O1 HASTE ( I W PRODUCT <br /> _ ---- <br /> F. DOES THE CONTAINER STORE MOTOR VE I LE EL OR WASTE OIL ? I;j.1'O1 YES ( 1 02 NO IF YES CHECK APPROPRIATE BO%If51: <br /> 1 1 O1_ UILEADCD ( 1 02 REGULAR 1 3 PREMIUM l 1 04 DIESEL I 1 OS WASTE OIL 06 OTHER <br /> —___ <br /> V CONTAINER CONSTRUCTION <br /> A THICKNESS OF PRIMARY CONTAINMENT 2 S0 ( 1 GAUGE (N INCHES ( 1 CM ( 1 UNKNOWN <br /> B. ( 1 01 VAUL7E0 (LOCATED IN AN UNDERGROUND VAULT- �.K 02 NON-VAULTED 1 1 Ol UNKNOWN <br /> 1C. 1 1 01 DOUBLE W%LLEDDL 1,02 SINGLE WALLED 1 ) 03 LINEO <br /> 0. ( 1 01 CARBON STEEL -'l 02 STAINLESS STEELy,,//Y;/03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 OS CONCRETE <br /> 1 106 ALUMINUM 1 1 07 STEEL CLAD ( I OE BROIIZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UIIKNOW14 l 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />