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4/ �.. <br /> STATE Ip NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Ix) 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> E 1 02 CONDITIONAL PERMIT [ ) 06 AMENDED PERMIT ( ) 08. MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> 144 f(COP OR T ON.INC VIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> tJ F ! <br /> 01 FED 1 3 02 STATE ( ) 03 LOCAL <br /> CITSTA /y ZIP q r, � <br /> II [FACILITY <br /> FACWTY NAME 0E/311 F R EN PERVI OR <br /> I/J� <br /> isTPEp, ACD?ESS NEARE,?T CROSS STR T. ' <br /> �CITY CCK— COUNN' IIP J( 4 <br /> MAILING ADDPESS � � CITYrf STATE ZIP <br /> PHONE W%AVEACODE TYPE Cr BUSINESS <br /> ( ) 01 GASOLINE STATION ) 02 OTHER <br /> NUMBER CF CONTAINEPS RURAL AREAS ONLY FO .4sH <br /> III Z4IP RANGE SECTION <br /> 4HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAKE(LAST NAME TIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> z u r �- dom <br /> - <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): YEAR MFG: C. YEAR INSTALLED (L-�UNKNOWN <br /> D. CONTAINER CAPACITY: �fJ GALLONS [ ) UNKNOWN E. DOES THE CONTAINER STORE: dY"01 WASTE [ 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> i ) 01 UNLEADED ( ) 02 REGULAR ( ) D3 PREMIUM l 1 04 DIESEL [r..Y05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE [ ) INCHES ( ) CM ()'UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. t ) 01 DOUBLE WALLED ( -1'02 SINGLE WALLED l } 03 LINED <br /> 01 CARBON STEEL l 1 02 STAINLESS STEEL { ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BR014ZE 1 ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1") <br /> 12 UNKNOWN ( } 13 OTHER: <br /> HSC04-070185 PAGE I <br />