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c(VI <br /> • QU a / <br /> STATE ID NUMBER <br /> r APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> I l ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT 7 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> L (XX 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT BR"CM'ATR'ETNO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> East Bay Municipal Utility District ( ) 01 FED ( ) 02 STATE 1 ! 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 2130 Adeline Street Oakland CA 94607 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR /vl� zl,✓ �V G <br /> Stockton Center zO y 5'63-ZY <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1804 West blain Street Los Angeles <br /> CITY COUNTY ZIP <br /> Stockton <br /> MAILING ADDRESS CITY STATE IIP <br /> P.O. Box 24055 Oakland CA 94623 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 415-835-3000, Ext. 569 1 ) 01 GASOLINE STATION (X) 02 OTHER Municipal Utility <br /> NUMBER OF CONTAINER$ RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> F011I <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LA$T NAME FIRST) AND PHONE W/AREA CODE <br /> Mai;habu( E 11 , ^M a�� �nnn, yl,�l - <br /> i'Ji2�riu'd) /;+�gx✓Cr5 6?-LD/' 3 Jf�izu/✓� �/'-�✓c�s 20i�,- c/o3 Z;j� - <br /> CCMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 46964 <br /> Unknown <br /> B. MANUFACTURER (IF APPROPRIATE): Unknown YEAR MFG C. YEAR INSTALLED O(1 UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( l UNKNOWN FE, DOES TME CONTAINER STORE: ( 101 WASTE ( ) 02 PRODUCT Empty <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES IX)Z 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED If 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL 0 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES [ ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL l l 02 STAINLESS STEEL 1 l 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> [ ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE f ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( X) 12. LNKNO144 ( ) 13 OTHER: <br /> HSC04-070165 --- PAGE 1 <br />