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*low Lw STATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 101 NEW PERMIT ( 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED 1 ) 09 DELETC FROM FILE (NO FEE) <br /> K11, 02 CONDITIONAL PERMIT -1 1 06 AMENDED PERMIT 1 1 00 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> HAY.E(COPRORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED 1 1 02 STATE L 1 03 LOCAL_ <br /> STPE •C •S 'J l CITY STATE IIP <br /> 2&kacs ���� <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMENISUPERVISOP <br /> 5 I <br /> STREET A002 NEAREST CROSS STREET <br /> eoDNTr IIP P Ee JIF1I`�p� <br /> MAILING ADDRESS ray /�� � CITY STATE 2IP <br /> PHONE WA-EA CODE TYPE OF BUSINESS <br /> �r l 1 01 GASOLINE STATION OG1 02 OTHER aK �! / <br /> HVMDFf CF CONTA2 Nf PS RURAL AREAS ONLY TOWNSHI• RANG! SlCTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) NO PHONE W/APER CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> Kr5 -R -7777 ` <br /> fiI�F <br /> OMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> ••": c A. 1 01 TAtM 1 1 02 OTHER: CONTAINER NUMBER — Q� <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR—INSTALLEO ff79(1 UNKNOWN <br /> D. CONTAINER CAPACITY: (D,O F 7 GALLONS 1 1 11NCNONN E. ODES THE CONTAINER STORE: ( 1 O1 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES ( 1 02 NO IF TES CHECK APPROPRIATE BO%IESI: <br /> C)C1 01 UlNLEAOED t 1 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL t 1 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICF.NESS OF PRIMARY CONTAINMENT _l I GAUGE 1 ) INHES ( 1_CM—1 1 UNKNOWN <br /> B. 1 7 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ()1 02 NON—VAULTED ( 1 03 UNKNOWN <br /> 1C. 1 1 01 DOUBLE WALLED (.6 02 SIfiGLE WALLED 1 1_03 LINED <br /> D. 1 1 01 CARBON STEEL I 1 02 STAINLESS STEEL —L16— 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( 1 06 ALUMINUM 1 ) 07 STEEL CLAD 1 1 09—UONZE i 1 09 COMPOSITE l ) 10 NON—METALLIC <br /> ( 1 12 UNKNOW)) 1 1 13 OTHER: _ _ -- <br /> . . PAGE 1 <br /> /ISC04-070185 'L ' <br />