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STATE ID NUMBER <br /> APPLICATION ,FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> LV 01 NER EERMIT ( l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CON TIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br /> I OWNER k <br /> NAME(COPPORATION,INDIDU L OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> i ' Luz gl �g ( ) 01 FED ( l 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS U ti CITY STAT ZIP <br /> v .2007' ( �z <br /> II FACILITY <br /> FACILITY NAME oe, DEALER/FOREMEN/SUP RVISOR <br /> L_ <br /> STREET ADD?ESS ,- 9 NEAREST CROS STREET <br /> CITY COUNTY ZIP _ <br /> - <br /> MAILING ADDPESS CITY STATE ZIP <br /> PHONE WiAFE4 CODE TYPE OF BU NESS-,20a 5 2. _ (X) 01 GAS O INE ST ION ( ) 02 OTHER <br /> NUMBER CFCONTAINERSRURAL AREAS ONLY T SHIP RANGE SECTION <br /> I/- _-- <br /> III 24 HOUR EMERGENCY CONTACT PERSO <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NI TS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE F M FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (>4- 01 TANK ( 1 02 OTHER: C TAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (V UNKNOWN <br /> D. CONTAINER CAPACITY: ZkV ALLONS i ) UNKNOWN E. DOES THE CONTAINER STORE:�&=ol <br /> WASTE t ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOT R VEHICLE FUEL OR WASTE OIL ? (X1 01 YES ( ) 02 NO IF ES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 RE LAR ( ) 03 PREMIUM ( 1 04 DIESEL PQ 05 WASTE OIL ( ) OTHER <br /> V CONTAINER CON 4RUCTION <br /> A. THICKNESS OF PRIMA CONTAINMENT: , a GAUGE ( l INCHES ( ) CM ( ) UNKNOWN <br /> B. ( l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WALLED (A 02 SINGLE WALLED ( ) 03 LINED <br /> D. �O1 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> L ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />