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\ / STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> l ) 01 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED l ) 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 COIWITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.I NOIVSDTVAI OR FUB II IC A1GENCY) PUBLIC AGENCY ONLY <br /> �_Q._.,_,.Ny.Z c)TSC VLEY' Sr ( 1 Ol FEB 1 1 02 STATE (✓1 03 LOCAL <br /> STREET ACOPESS CITY STATE ZZP <br /> Z V <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPERVISOR <br /> a— <br /> STREET RCC°ESS NEAREST CROSS <br /> /1STREET <br /> CZL{r <br /> Ca. <br /> 9524.0 COUNTY ZIP <br /> MAILING ADDRESS CITY STATE ZIP <br /> PHONE W,ACEA'MCO/DE TYPE Of BUSINESS <br /> 90,9-ns-a7 lM ( ) 01 GASOLINE STATION ( 1 02 OTHER <br /> ( <br /> NUMBER Cl CONTAINERSRURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> I <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NA M,E(LAST NAMC`fIP15T1 AND PHONE W4EA CODE NIOXTS: NAME(IAST NAME FIRST) AND PHONE W/AREA`C'DE�� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1/01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR .INSTALLED 71 1 ) UNKNOWN <br /> D. CONTAINER CAPACITY: 1600 GALLONS V) LMNGM DOES THE CONTAINER STORE: (yl 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 O1 TES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 <br /> 01 UNLEADED 1 1 02 REGULAR 1 ) 03 PREMIUM ( ) 04 DIESEL 1�4 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TH ICY.NESS OF PP.IMARY CONTAINMENT: ( 1 GAUGE 1 1 INCHES ( ) CM (L UNKNOW! <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED 1W03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( 1 02 SINGLE WALLED 1 ) 03 LINED <br /> D. ( 1 01 CARBON STEEL l ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 06 ALUMINUM l 1 07 STEEL CLAD ( 1 08 BRONZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 112 UNKNOW) ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />