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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 01 NEW PERMIT l 105 RENEWED PERMIT ( ) 07 TANK CLOSED 1 1 09 DELETE FROM FILE (NO FEE) <br /> IIr 1 1 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> i5pyo O,l co l 1 01 FED 1 1 02 STATE f 1 03 LOCAL <br /> STREET ADORESS CITY STATE ZIP <br /> 1221 E Ma.h Sf ^ lFavoo o- TJ 3408 <br /> II FACILITY <br /> FACILITY 44ME DEALER/FGPEMENISUPERVISOR <br /> "TET <br /> STREET AOD'ESS NEAREST CROSS STREET <br /> CITY COUNTY ZIP <br /> 12Re`I \\ Jan .doe Ca LA�r, g531(o <br /> MOILING PDOPESS C4 wren O ¢e) CITY STATE ZIP <br /> _ Po 130.4 69 soquel CIa I 4soo3 <br /> PHONE W!�APEA CODE TYPE OF BUSINESS <br /> 4mj-91.2 1j01 q) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF—CONTAINERS DURAL 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 /> Green L Y do 0041) -Y3a7 44)S Green l -n 9o4 X36- 1093 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. Ox 01 TANK ( 1 02 OTHER: � 1CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): NoDERp W�.`Din�= Gc.psTeE1 YEAR MFG: 193(p C. YEAR INSTALLED UNKNOWN_ <br /> D. CONTAINER CAPACITY: 10,60�, GALLONS l 1 UNKNOWN E. DOE5 THE CONTAINER STORE: L 1 01 WASTE l'() 02 PRODUCT — <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES l 102 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> I I 01 UNLEADED (X) 02 REGULAR 1 1 03 PREMIUM l 1 04 DIESEL l 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: /q ( 1 GAUGE (x) INCHES ( 1 CM ( 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ) 02 NON-VAULTED ( 1 01 UNKNOWN - <br /> C. (xl 01 DOUBLE WALLED 1 ) 02 SINGLE WALLED 1 1 03 LINED <br /> D. DC) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> I ) 06 ALUMINUM 1 107 STEEL CLAD 1. 1 OB BRONZE 1 ) 09 COMPOSITE l 1 30 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13. OTHER: <br /> HSC04-07-0185--- --- PAGE 1 <br /> f <br />