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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> l ,al NEW PERMIT <br /> ( ) OS RENEWED PERMIT [ 7 07 TAMC CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ! 08 MINOR CHANGE [NO SURCHARGE( <br /> I GONER <br /> PUBLIC AGENCY ONLY <br /> NAME(CORPOR ATION.INDIVID UAL OR PUBLIC AGENCY) ( ) 01 FED ( ) 02 STATE B<r 03 LOCAL <br /> oQ. (D✓1 t G <br /> STATE 2c1 7 7 <br /> STRlET ADDRESS � 0. <br /> 1 <br /> II FACILITY <br /> FACILITY NAME OE FOR EmAH/51 <br /> n RVISOR <br /> IV1/% SQL erVtsol�' <br /> NEA ST OR SS STRE <br /> STREET ADDRESS � <br /> � ZU L <br /> COUNTY T'T� ZIP <br /> CITY San ,JL)Q a i } <br /> CITY STATE Z� �� <br /> MAILING ADDRESS <br /> I t <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> d ( ) 01 GASOLINE STATION ll> 02 OTHER <br /> NUMBER OF CO TAINERS <br /> U RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY : NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(IAST NAME FIRST) AND PM /ARE/ CODE <br /> DA�: NAME(LAST NAME FIRST) AND PHONE W <br /> r 20 -8--4 3- 3 1 d j ll 3 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION - <br /> C T R NUMBER �O I <br /> A, 1 TANK ( 1 04 OTHER: <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG,. C. YEAR INSTALLED 1 UNKNOWN <br /> D. CONTAINER CAPACITY:�Q/(ZnD GALLONS ( ] UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE ,=02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? CW O1 YES t ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> :9 O1 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIES'( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( 1 INCHES ( ) CM _(:hl-UNKNOWN <br /> B. ( ] 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) V 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t 1 01 DOUBLE WALLED (le SINGLE WALLED ( ) 03 LINED <br /> D ( 1(0) CARBON <br /> STAINLESS <br /> STEEL( 08BRONZEBRONZEFIBERG009SCOMPOSITE PDL) 10YNON-METAD05 CONCRETE <br /> 03 NON-METALLIC <br /> ) <br /> V�-12 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> H5C04-070185 <br />