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l L�'V� t'l �.�� �,' � �IT• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 101 NEW PERMIT ( ) OS RENEWED PERMIT t 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FE E1 <br /> ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 1 04 MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> VAY.E(COPPORATION.INNDDIVIDUA�L pOlt PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> _f 1lwnN IJOW(J[�C. 1 1 01 FED 1 ) 02 STATE 1 ) 03 LOCAL <br /> STP C'T, A�CORISS CS STATE zIP <br /> LJ1 l._ 9f726 <br /> [I FACILITY <br /> FACILITY NAME DEALER/FOPEMEN�S PERVISOR <br /> , ymr,D <br /> STREET AOOPPS9 NEAREST CROSS STREET <br /> 1366 n_CAJl,, (atilt Sr CJAA. - <br /> CITY Co NTY zzv <br /> 5datA •- TlY ek . r7-z,6 <br /> MAILING $OXSS CIC S SCR'.TE z9) / <br /> PHONE W/AREA CODETYPE OF BUSINESS <br /> )A-#*- 393-L l)l 01 GASOLINE STATION 1 ) 02 OTHER <br /> NVMDER 4GF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: HAY.E(LAST NAME FIRSTI AND PHONE W/ARCA CODE NIGHTS: NAME)LAST NAME FIRST) AND PHONE W/AREA CODE <br /> U014, (_bm of 104 frb- ?4 r2- sr.� - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 01 TAW ( 1 02 OTHER: CONTAINER NIRSBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED // ( ) UNJ04N <br /> ID. CONTAINER CAPACITY: 7j SU GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 1 ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? I 0 YES ( 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 l 01 UNLEADED f ) 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIE ll 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM 1 ) UNKNOWN <br /> S. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 2 SINGLE WALLED f ) 03 LINED <br /> D. ) 01 CARBON STEEL [ ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />