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` C11-:s <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEET <br /> l ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.IHDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( 1 1 01 FED 1 ) OE STATE ( ) 03 LOCAL <br /> STREET ADDRESS C Y STATE ZIP <br /> CA . <br /> II FACILITY <br /> FACILITY NAM! DEALER/FOREMEN/SUPERVISOR <br /> (�� <br /> e. <br /> .71 <br /> STREET ADDRESS NEAREST CROSS STREET <br /> d <br /> Aj J�ZIPCITY i � Jq <br /> MAILING ADDRESS CITY STATE ZIP <br /> IF <br /> . ON- W/APEA CODE TYPE OF BUSINESS <br /> I (Li-fi GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/ARCA CODE NIGHTS: NAME(LAST NAME FIRST)-AND-PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( TANK ( .1 02 OTHER: CONTAINER NUMBER 2Ak <br /> B. MANUFACTURER (IF APPROPRIATE): � Crj ) YEAR MFG:4ew C. YEAR INSTALLED (VrUNKNOWN EA <br /> 0. CONTAINER CAPACITY: rjrjp GALLONS f 1 UNKNOWN E. DOES THE'CONTAINER STORE: ( O1 WASTE ( 102 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (6t-01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED 1 ) 02 REGULAR 1 ) 03 PREMIUM ( ) 04 DIESEL (L.1-05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES 1 ) CM (L.1-DRKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 0-0-2 NON-VAULTED 1 ) 03 UNKNOWN <br /> C. (VI"01 DOUBLE WALLED ( ) 02 SINGLE WALLED l 1 03 LINED <br /> 0. 1 ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( Q-n FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM ( ) 07 STEEL CLAD l l 08 BRONZE 1 1 09 COMPOSITE f 110 NON-METALLIC <br /> 1 ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />