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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> j�l NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I GONER <br /> NAME(CORPORATICN,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> � Q S � ( ) 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS (O UIJIVE_(26.AL. G(TY PLAZA CITY UNkVC-tUA(. 0T ( STATE ZIP 91608 <br /> �. 0. • U 370'6 1 c n <br /> II FACILITY <br /> FACSIITY NAME DEALER/FOREMAN/SUPERVISOR <br /> Rl-0 �' .0-teAc4- a .l e.4t;d <br /> STREET ADDRESS NEAREST CROSS STREET <br /> "' ti b w Q41"It , Lo �,1 0-f <br /> CITY11__ COUNTTYZIP <br /> ^ <br /> MAILING ADDRESSCITY STATE ZIP <br /> ^1yC� w . Chc��2 w 3J61k-�,A-) <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 01 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/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> ALO CkSlorn�2 SCC ,L0 �E' A;�2 A)21cl, Dqj.-d cfl(o - `i bb-3`' ! O� <br /> ocu) �L3) - 3iv3 a 3(v —00tQ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 01 TANK ( ) 04 OTHER= CONTAINER NUMBER <br /> x�12X C$ l9b� <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> 0. CINER CAPACITY: ,���(�j GALLONS ( ) UNKNOWN E. GOES THE CONTAINER STORE: ( 1 01 WASTE (XJ 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? GN 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (-A 01 UNLEADED ( ) 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM .l\) UNKNOWN <br /> S. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ((.02 SINGLE WALLED ( ) 03 LINED <br /> 0. 1',A 01 CARBON STEEL ( ) 02 STAINLESS STEEL 04� 03 FIBERGLASS l ) 04 POLYVINYL CHLORIDE ( ) 05 COi1CRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />