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STATE YD NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 OY NEW PERMIT ! 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( 1 09 DELETV FROM FILE (NO FEE) <br /> — f —1 02 CONDITIONAL PERMIT _1 ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INCIVIOUIL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> — C M(ZL � A E w, al FED 1 ) 02 STATE ( 1 03 LOCAL <br /> STcEEi AC7RE55 CI Y STATE ZIP <br /> ss <br /> II FACILITY <br /> FACILITY NA.—.E DEALER/FOPEMEN//SVPERVISOP} <br /> STFEET ADD°ESS NEAREST CROSS STPEET <br /> rLLA RD <br /> CITY COUNTY ZIP <br /> 1�r c r� SAN J <br /> MAILING APOPESSCITY STATE TIP <br /> .PHONE WIACEA CODE TYPE CF BUSINESS <br /> 2-"" C� �� ( 01 GASOLINE STATION [ 1 02 OTHER <br /> NUP'.BEP CF CONTAINECS PUPAL APEAS ONLY : TOW,NSFIP RANGE SECTION. <br /> Ill 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIPST) AND PHONE. W/APER CODE 'NIGHTS: NAME{).AST NAME FIPST) AND PHONE W/APEA CODE <br /> 33 <br /> ia <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> " < A. (X) 01 TAIIK f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE)= YEAR MFG: 81 C. YEAR INSTALLED 1981 { ) UNKNOWN <br /> 0. CONTAINER CAPACITY: 6000 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE §C ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? V, 1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ESI' <br /> !X1 01 UNLEADED ( 1 02 REGULAR 1 ) 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS Of PRIMARY CONTAINMENT: f ) GAUGE ( 1 INCHES ( i CM (X ) UNKNOWN <br /> B. f 1 01 VAULTED !LOCATED IN AN UIJOERGROUND VAULT ( )e 02 NON-VAULTED f ) 03 UNKNOWN <br /> 1C. f 1 01 O011BLE W1LLEO (X) 02 SINGLE WALLED 1 1 03 LINED <br /> 0. IX) 01 CARBON STEEL f ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( 1 0,5 ALUMINUM f 1 07 STEEL CLAD f 1 06 BRONZE I f 09 C011POSITE ( ! 10 NON-METALLIC <br /> 1 ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSE04-0 0185 PAGE 1 <br />