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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT f ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I CONE <br /> NAME( RPpRATICN.I IVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> .J Q T C f 1 O1 FED 1 ) 02 STATE (-%t LOCAL <br /> STREET ADT�SS I/O SJ I CITY .yam ` STATE Z4, <br /> II FACILITY _ <br /> FAG I Y NAME DEALER/FOREMAN/SUP RVISOR <br /> '� a T o Sefvlc Cfru I�cssu- Li <br /> SfAper✓�sa <br /> -- <br /> S EET A DRESS z NEA EST Ca QSS STRE T <br /> CITY COU Y --. ZIP <br /> 1 rac air �p 0 U,l N `%s3 lv' <br /> MAILINGG ADOR SS n CITY„^_--- STATE ZIP <br /> S 1 KKJ r 9�3 <br /> PHJ�EW/APEA CODE_/� �� TYPE <br /> O3 GASOLINE STATION 1 ) 02 OTHER Y"_. YOLY�Q <br /> X1`'—_3 — <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <br /> III X24 HOUR EMERGENCY FIRST) ONEERGENCY CONTACTT PERSON <br /> AND <br /> PW I c,*- <br /> DAYS:L.Y�.U.(V� NAP <br /> � aO EA CODE N NAME(LAST NAME 0 S4S-PHONE <br /> 7�S EAOCODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION y <br /> A. ( O1 TANK f 1 04 OTHER= CONTAINER NUMBER 1 — <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED j 7 /( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: SQW GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (x),02 PRODUCT <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 0<1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED 1 ) 02 REGULAR (x) O&PJLEMIUM 1 ) 04 DIE5�7' f ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: l ) GAUGE ( ) INCHES ( ) CM )rUNKNOWN <br /> B. [ 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Nr OZ NON-VAULTED f ) 03 UNKNOWN <br /> C. t ) 01 DOUBLE WALLED l�2 SINGLE WALLED ( ) 03 LINED <br /> D. 1 ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS 1 ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM l 1 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 7}2 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />