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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT f ] 05 RENEWED PERMIT ( ) 09 DELETE FROM FILE (NO FEE) <br /> l ) 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT 1 ) GE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPOP TION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> :iovJJjjJJ�? Co., ( ) 01 FED f ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDPESS CITYSTAT ZIP <br /> II FACILITY <br /> FACII Y NAME DEALER/FOPE EN/SUPERVISOR <br /> STREET AODIESS NEAREST CROSS STREET <br /> tAlf 1457 <br /> CITY CO NTY ZIP �q <br /> W <br /> MAILING ADDPESS CITY STATE ZIP <br /> PHONE WiP�EP CODE TYPE 0 BUSINESS <br /> 01 GASOLINE STATION ( ) 02 OTHER <br /> - x Sl <br /> NUMBER OF CONTAINERS RVRAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY NAY,Ef LAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> G X77 9yo/a 799/ 5�of <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> 1 <br /> A. ( ) 01 TANK f ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): - YEAR MFG: C. YEAR INSTALLED// C ) UNKNOWN <br /> D. CONTAINER CAPACITY: 1/000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ] O1 WASTE MJ 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 5Zj 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> LX)( ) 01 UNLEADED ) 02 REGULAR t ) 03 PREMIUM ( ) 04 DIE EL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f ) INCHES ( ) CM (4UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) !41) 02 NON-VAULTED t ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED l ) 03 LINED <br /> 0. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE 1 1 09 COMPOSITE f 1 10 NON-METALLIC <br /> (�1 12 UNKNOWN ( l 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />