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Y <br />4w i <br />STATE I0 NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />( ) <br />01 NEN PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( .D 09 DELETE FROM FILE (NO FEE) <br />1 J 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT' ( ) 00 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />N`'A'ME(CORPORATION,%NCEVIOUAL OR PUBLIC AOE CY) __fPUBLIC AGENCY ONLY <br />Union Oil C.om y of 6aliroroja P: c�ba t ) O1 FED 1 ) 02 STATE ( ) 03 LOCAL <br />STREET: ADDRESS <br />zin, N. ealil r„(c� Blvd.-, witei 650 Walt1at C mzk STAse-A ZgZP cQ/ <br />II FACILITY <br />FACILITY NAME <br />( D 01 TAW t D 02 OTHER: <br />DEALER/FOPEMEN/SUPERVISOP <br />CONTAINER NUMBER <br />STREET ADCPESS <br />MANUFACTURER (IF APPROPRIATE): <br />NEAREST CROSS STREET <br />YEAR INSTALLED ( D UNKNOWN <br />CITY <br />CONTAINER CAPACITY: GALLONS t D UNKNOWN <br />COUNTY <br />CONTAINER STORE: t 1 01 WASTE t D 02 PRODUCT <br />ZIP <br />MAILING ADDRESS <br />01 YES t D 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 05 WASTE OIL ( ) 06 OTHER <br />CITY <br />STATE <br />ZIP <br />PHONE W/AFEA CODE! <br />TYPE OF BUSINESS <br />' <br />t ) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHEP <br />RANGE <br />SECTION <br />I1I 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRSTI AND PHONE W/AREA COOS <br />HG Faflahe. <br />R.L. {419) 945 -7Co7Cn - - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />( D 01 TAW t D 02 OTHER: <br />( ) GAUGE t i INCHES ( ) CM l 1 UNKNOWN <br />CONTAINER NUMBER <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG:C. <br />YEAR INSTALLED ( D UNKNOWN <br />D. <br />CONTAINER CAPACITY: GALLONS t D UNKNOWN <br />E. DOES THE <br />CONTAINER STORE: t 1 01 WASTE t D 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL? ( ) <br />( ) 01 UNLEADED ( ) 02 REGULAR t D 03 PREMIUM ( ) OA DIESEL <br />01 YES t D 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: <br />( ) GAUGE t i INCHES ( ) CM l 1 UNKNOWN <br />01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) t ) 02 NON -VAULTED f D 03 UNKNOWN <br />(C. <br />t ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( <br />1 03 LINED <br />D. <br />( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL t <br />t ) 06 ALUMINUM ( ) 07 STEEL CLAD t D 08 <br />t ) 12 UNKNOWN ( ) 13 OTHER: <br />1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE t D 05 CONCRETE <br />BRONZE t J 09 COMPOSITE ( ) 10 NON-METALLIC <br />csc®�-o70it35 PAGE 1 <br />