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STATE IO NUMBER <br /> t - <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> xl O1 NEN PERMIT l 1 OS RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09'DELETE FROM FILE (NO FEE) <br /> I 1 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (NO SURCHARGE) 1 <br /> I OWNER <br /> NAY.!(COPPORATION•INOIVIDVAL OP PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> U 1 1 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> STP!CT AM RE-S -------- <br /> _ 7..0a__ LLr ar� �_ _--_ D> urIt ntmt Scvrt�21 0/b <br /> II FACILITY <br /> FACILLITY NAME DEALER/FOPEMENISUPEPVISOP <br /> A <br /> STREET AOL1ES2 NEA ST QR Sq S STVIET <br /> CITY C NpyL TY ZI <br /> MAILING ADOPESS CITY STATE ZIP <br /> PHONE WAVE. COO �.p T LAPEA.L.H&L <br /> OF VSINESS <br /> l GASOLINE STATION ,� 02 OTHER <br /> NUMBER CF CONTA14EPS PUPY TOWNSHIP PANOE - SECTION <br /> (III 24 HOUR EMERGENCY CONTACT PERSON <br /> ST <br /> IDAY��IAAM�2T1 AND PHOyE LL j/Aq/\FA C OOF-�o� NIONTS: NAMCIIAST NAME PIRST I-AND PHONE WYAPEA CODE 1COMPLETEC- F1�THE FOLC/LLOWSING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (/-4 01 TAf RC l _1 02 OTHER_ - CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): (OCA)a4-6 21 - YEAR MFG: C. YEAR INSTALLED l ( �Jp(-1 UNKNOWN 1 <br /> D. CONTAINER CAPACITY: f-Q O GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE 1 02 PRODUCT <br /> F. DOES THE CONTAI14ER STORE MOTOR VEHICLE FUEL OR WA TE OIL ? 01 TES 1 1 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> I 1 01 UNLEADED ( 1 02 REGULAR t 1 03 PREMIUM . ( 1 04 OI SEL ( 105 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> �A. THICt NFSS OF PP.IMARY CONTAINMENT I 1 GAUGE ( 1 INCHES 1 I CM I 1 UNKNOWN <br /> [[[ <br /> B. f 1 Ol VAULTED )LOCATED IN AM UNDER GR OUNO VAULT) I�I 02 NON-V AUL7E0 1 1 OS UNKNOWN I§,1 <br /> iC. 1 01 DOUBLE WILLED ( 1 02 SINGLE WALLED ( 1 03 LINE0 -JAN <br /> 0. 1 1 QJ-CARBOfI STEEL 1 1 02 STAINLESS STEEL07 STEEL CLAD - -03-FIBERGLASS ( -1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> Ot ALUMINUM 1 1 1 1 OB BRONZE 1 1 09 COMPOSITE I 1 10 NON METALL Ifs <br /> i/ 6 ALUM l 1 13 JTHER: C1iVIf(l.'IViti�lAL H L-A <br /> - - -f-ERI\41T/SERVICES <br /> PAGE 1 <br />