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STATE ID NUMBER <br /> APPLICATION FOPERMIT TO OPERATE UNDERGROND 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 ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMEICOPPORAT Nto�INDIVIDUAL �Og PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> P T // ( )0 if 01 FED f 102 STATE ( 1 03 LOCAL <br /> STREET RESS , /+. �'f N �7- CITY ^� STATE �P 3 6� <br /> II FACILITY <br /> FACILITY NAME J9 SIQC..�S DEAL ER/POPEMEN/SUPERVISOR, <br /> STREET ADDPESS NEAREST CROSS TREET <br /> 12T F. *ahu ckowL P-, <br /> CITY COUNTY - ZI��_� <br /> CA, <br /> Saw JO vl.v <br /> MAILING ADDRESS O CITY ; STATE ZIP �� / <br /> PHONE Wi AREA cooE - TYPE <br /> 1 01 GASOLINE STATION 10-12 OOTHHEERv <br /> NUMBER OF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,E)LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND..PHONE W/AREA CODE <br /> ZD£ rpbeYT �D9 S99-z/.?�' -��� IPo6e.T X 09— S9�3119 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 01 TANK ( ) 02 OTHER: CONTAINER NUMBER / <br /> B. MANUFACTURER (IF APPROPRIATE): N YEAR MFG- f93C. YEAR INSTALLED `S3 ( I UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS l I UNKNOWN E. DOES THE CONTAINER STORE: f 101 WASTE 02 PRODUCT <br /> F. DQF/8 THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? d, 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( UNLEADED f 1 02 REGULAR ( 1 03 PREMIUM ; 104 DIESEL ( 105 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1.`�y ( AUGE f ) INCHES ( ) CM 1 ) UNKNOWN <br /> B. 'r ) 01 VAOMD (LOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED l 1,02, SINGLE WALLED 1 103 LINED <br /> D. t O1 CARBON STEEL ( 102 STAINLESS STEEL ( 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> f ) 06 ALUMINUM l ) 07 STEEL CLAD ( 108 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 1 1 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />