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STATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (RC1 01 NEW PERMIT ( I CS RENEWED PERMIT ( 1 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> 1 ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( l 06 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAIoR PLtaLIc AGlNcrl PUBLIC AGENCY ONLY <br /> UNI()tJ OIL- Co1+nPAPJy OF CAL iFORNIA� db,, fWN©CAL C 1 01 FED ( 1 Ot STATE C ? 03 LOCAL <br /> - ---- � 1-`-� CITY STAT! ZIP <br /> srar{r ADnRESS \A/Ar� Nie 1C C 416 <br /> 2175 IVo( r1t G4L ip-oq 4(,4 91-UD 441Te (160 <br /> I1 FACILITY <br /> FACILIT7 KAME DEALER/FOREMEN/SUPERVISOR <br /> L4NO64,L 15a\Ac.0 5-r4 4r 63115 D. FERCzu5drJ z IF• IWE-WHAU , jr, <br /> STREET ADOPESS NEAREST CROSS STREET <br /> 3788 -Wc-r N-va. HWY 2-05 P <br /> CTFr ,AG l cS <br /> caUNTrA�l JOAQL41t-1 zIP� 7b <br /> MAILING ADDRESS CITY --�1-�AG..� STATE ZIPQ5 <br /> 3703 �(_,r bi-VD sl~ CA 76 <br /> PHONE W/AFEA CODE TYPE OF OUSINESS <br /> �zf�) 636 — Q61t6 C�C1 01 GASOLINE STATION ( I 02 OTHER <br /> NUMaER OF CONTAINERS RURAL AREAS ONLY TOWHSHIF RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM{iLAST NAME FIRST) AND PHONE W/AREA COD! NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/Aq{A 000E <br /> Mc FAKLArJt gANDY C�)5) qq5--7676 UNOC-A1— � 15) 561- 'T322- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TANK (-1 02 OTHER: CONTAINER NUMBER <br /> 5. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 117z C. YEAR INSTALLED 197Z ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 5-50 GALLONS t 1 UNCNOIH E. DOES THE'CONTAIHER STORE- Cq 01 WASTE i 1 02 PRODUCT <br /> F. ODES THE CONTAINER STORE MOTOR VEHICLE FUEL OR R 5TE OIL ? 0-0 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> ( 1 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREIIIUM ( 1 04 DIESEL (}d 05 WASTE OIL ( 1 05 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: R. C . S, l 1 GAUGE ( I INCHES ( 1 CM i ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULTI i,\l 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (,KI 02 SINGLE WALLED ( 1 03 LINED <br /> D. (XI OL CARBON STEEL ( 1 Ot STAINLESS STEEL ( 1 03 FI9ERQLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ! 07 STEEL CLAD ( 1 Oa BRONZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> C 1 12 UNKNOWN ( 1 13 OTHER <br /> . HSC04-070185 <br /> PAGE I <br />