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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (>4 01 NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> 0 ON E R - <br /> UBLIC AGENCY ONLY <br /> NAME(COPPORATION,INDXIIDUAL OR P LIC AGENCY) <br /> (J,}-01 FED 02 STATE 03 LOCAL <br /> STPEET,tDDRLSS STATE ZIP <br /> CITY <br /> 191-5 <br /> FACILITY <br /> DEALER/FOREMAN/SUPERVISOR <br /> F A C I L,;,TV I�NAME <br /> STREET A Ry S <br /> NEAPEll_c... STREET <br /> Iv d <br /> iv <br /> C <br /> Y ZIP <br /> P <br /> CITY M, <br /> CA_ 9 <br /> CITY LC STATE ZIP <br /> MAIL INGXO PISS A <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION t-A 02 OTHER <br /> NUMBER OF CONTAINERS J�RURAL AREAS ONLY TOWNSHIP RANGE <br /> SECTION <br /> 111 24 HOUR EMERGENCY CONTACT PERSON <br /> NIGHTS: NAME(LAST�NAME�FIRST) AND PHONE W/AREA CODE <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/;AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. CONTAINER=NUMBER <br /> MB <br /> 4-VI TAW 04 OTHER' <br /> C I -UNKNOWN <br /> YEAR MFG: C. YEAR INSTALLED <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> D. CONTAINER CAPACITY: 5-OVV GALLONS UNKNOWN E. DOES THE CONTAINER STORE: 01 WASTE (.&L 02 PRODUCT <br /> - <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (70 01 YES 02 NO IF YES CHECK APPROPRIATE BOX ES) <br /> ,�� <br /> 01 UNLEADED 02 REGULAR 03 PREMIUM (>O 04 DIESEL 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM (>q-UNKNOWN <br /> B. t I ol VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 01 DOUBLE WALLED ()<f 02 SINGLE WALLED 03 LINED <br /> D. C4 01 CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> ) 06 ALUMINUM 07 STEEL CLAD 08 BRONZE 09 COMPOSITE 10 NON-METALLIC <br /> 12 UNKNOWN 13 OTHER-' <br /> PAGE I <br /> HSC04-070185 <br />