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STATE IU NUMBER <br /> APPLIC.ATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (�O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 0@ MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(C pPORfTION,INDIVIDU.AL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED { ) 02 STATE ( ) 03 LOCAL <br /> STREET ADCPE5S CITYGG STATE ZZP <br /> II FArILITY <br /> k FACILITY NAME DEALER FCREMEN,/SUPERVISOP <br /> $`BEET fC0?ESS NEARES CROSS STREET <br /> CITY COUNTY ZIP <br /> MAILING ACOP.ESS CITY STATE LZIP <br /> © F <br /> C A <br /> { PHONE W/AvE4 CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION (a 02 OTHER <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY TOWNSHIP TAN13r; SECTION ; <br /> III 24 HOUR EMERGENCY - CONTACT PERSON <br /> { DAYS: NAME(LAST NAME FIPSTI AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> frl�y k <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR .EACH CONTAINER <br /> SIV DESCRIPTION <br /> 3 <br /> ( A. 01 TANK ( } 02 OTHER' CONTAINER NUMBER.lig <br /> B. MANUFACTURER (IF APPROPRIATE) �(� QG(If�+ YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> i� i <br /> 0. CONTAINER CAPACITY: CJ GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE= f ] 01 WASTE (� 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ?,1,,�4 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE SOX(ESI- <br /> ( O1 UNLEADED ( ) 02 REGULAR t ) 03 PREMIUM ( 1 04 DIESEL 1 } 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> Y <br /> A. THICKNESS OF PRIMARY CONTAINMENT- ( ) GAUGE [ I INCHES E ] CM UNKNOWN <br /> B. { ) 01 VAULTED (LOCATED IN AN UNOERGROUND VAULT) 02 NON-VAULTED ( } 03 UNKNOWN <br /> C. [ ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED l ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FI6ERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD [ 1 08 BRONZE f ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (J�3 12 UNKNOWN ( 1 13 OTHER- r <br /> HSC04�-074185 . PAGE 1 <br />