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• • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> OL NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 DELETE FROM FILE (NO FEE) <br /> !x`/'02_ CONDITIONALPERMIT <br /> —1 1 06 AMENDED PERMIT ( ) OB MINOR CHANGE (NO SURCHARGE) -- — _- - <br /> III OWNER 111 <br /> �NaM�ICOpPORArION.INC IV IDUAL OR PUBLIC AOINCYi PUBLIC AGENCY ONLY <br /> p�/_)1LtIuN lT��!N f.AJ _�"n9L S£RVEC�S f l 01 FED 1 l 02 STATE ( .) 03 LOCAL <br /> �Sr TSS CITY �S TAT F, Z P <br /> [667_w, w�}sNiu6mN B�✓�. _ _ �LoS ANsriLFS I ��• �oL7o7 <br /> ( <br /> II FACILITY <br /> I(F CIL•TV NNME DEALER/FCPEMEN/SUPERVISOP <br /> rr dFULD2 C/te� SLew,cE s -DRvc &EAvC--,es <br /> STREET ACO'ESS NEAREST CROSS STPEET <br /> 7// S. SAN ToAau( ST. N_42fiL7-0nl <br /> C: Y COUNTY ZIP <br /> STpGKTeN S AN vHQu)it/ 9s-.203 <br /> MAILING ADOPESS CITY STAT ZIP <br /> �--- <br /> �PNONF pWARE♦ CODE c, TYPEOF BUSINESS <br /> I 01 GASOLINE STATION 02 OTHER <br /> t4U"ER C` CONTAINERS RVP AI AREAS ONLY TOW YS NIP -- PANGE SECTION <br /> I:II 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAM.EILAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE WIAPEA CODE <br /> T3Fi4uFit o -Y6S-s2�8 ERU�2S4 DAv£ X09 41 7Y- 9�/9P -- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> 'A. 04 PI TANK ( 102 OTHER: CONTAINER NUMBE�- <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED Dq,UNKNOWN <br /> 0. CONTAINER CAPACITY:4"431- GALLONS I ) UNKNOWNE. DOES THE CONTAINER STORE: 1 1 01 WASTE M 02 PRODUCT <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL L.04.-01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> 1 1 01 UNLEADED Olq 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL f 106 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TM ICKNESS OF PRIMARY CONTAINMENT: l l GAUGE f 1 INCHES ( 1 CM 2SLJJNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l l 02 NON-VAULTED 114 03 UNKNOWN <br /> 1C. 1 101 DOUBLE WALLED ( 1 02 SINGLE WALLED 1 1 03 LINED <br /> 0. tR O1 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FI6ERGLASS 1 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> CX 3 OE ALUMINUM l ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> - ( 1 13 OTHER: <br /> NSC04-0I1185 PAGE 1 <br />