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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> I�1A 01 NEW'PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED f 1 09 DELETE FROM FILE-'('NO'FEEI I <br /> 1 1 ONOITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 09 MINOR CHANGE (NO SURCHARGE) ll <br /> I OWNER <br /> YAME![OP VCP AT 20INO IVIDV —0f— <br /> F 5LI-CA OENC PUBLIC AGENCY ONLY <br /> , �/� 1 01 FEB 1 1 02 STATE 1 / 03 LOCAL <br /> !-STREET ACTRESS �w. Y CIA. ST LI � <br /> II FACILITY <br /> IFACII 171 NAMEArco <br /> DEALER/PO PE MEN�S U P ERVISOP <br /> iTRCEF ACC'E SS NEAREST CROSS STREET <br /> 205 /�/• C.el..�tn _ <br /> �TY COUNTY ZIv <br /> �-- _ '75-2-o2 <br /> MA Il INGADgPESS CI se Z� �� J <br /> i T/LJ A <br /> PHONE WIAVEA CODE TYPE OF BUSINESS <br /> OQ 01 GASOLINE STATION f 1 02 OTHER <br /> NUMBER OF CONTAINEPS RURAL AREAS ONLY TOWNSHIP RANGE SECTION. <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> PAYS• NAME)LAST NAME FIPST AND PvnNE W/APEA CO^ SNI HTS: N4M fl ST NAME FSRSTI AND PHONE W�AREA CODE <br /> i �_tZQt7-: ¢��• 8 8 I ,�rcv �.� �.,.., �,1�P�Fs Fsoo-4z1 "14 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> X �A. I�A)K ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG. C. YEAR INSTALLED /167 1 1 UNKNOWN <br /> 0_CONTAINER CAPACITY rXtLONS 1 1 11NICNOWH E. DOES THE CONTAINER STORE: ( 1 01 WASTE ( JI 012 PRODUCT <br /> F. GOES THE CONTAINER STORE MOTOR VEHI LE FUEL OR WASTE OIL ? ()51 -!'ES l 1 02 NO If YES CHECK APPROPRIATE BOXES I: <br /> 1 1 <br /> 01 UNLEADED ( 1 02 REGULAR IUM 1 1 04 DI EL ( 1 05 WASTE OIL 1-=&06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: Q A24 o ( 1 GAUGE (-G -IUCHES l 1 CM 1 1 UNKNOWN <br /> 1 <br /> B. 1 01 VAULTED (LOCATED IN AN UHUERGROUND VAULT) l_ _VAULTED 1 103 UNKNOWN • - <br /> j IC. 1 l 01 DOUBLE WILLED ( INGLE WALLED ( 1 03 LINED <br /> D. 1 1 CARBON STEEL f ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLTVINYL CHLORIDE ( 1 05 CONCRETE <br /> f ( 1 06 ALUMINUM 1 1 07 STEEL CLAD ( 1 00 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN l 1 13 OTHER: <br />• NScoa-O;n105'__—_—__._.___—. --_. ___ —_______. _ — PAGE 1 <br /> i <br />