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�z <br /> ^ 14A 11//�(w STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE NDERGROUND STORAGE TANK <br /> ( 1 OS NEW PERMIT ( 1 05 RENEWED PERMIT 06 OT-TC10� ( 1 09 DELETE FROM FILE IND FEE) <br /> 1 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> ,AM.EICOPPORATION.INCIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> � I Q til k�64-y ( 1 01 FED 1 ) 02 STATE 1 ) 03 LOCAL <br /> :TPf CT ACA4CS2 CITY ST T ZIP <br /> S� <br /> I FACILITY <br /> 'ACILITY NAME , DEALER/FOPEMENISUPERVISOP <br /> :TRfET ADD-ESS NEAREST C4 SS STREET <br /> :ITY COUNTY S�IIIP LN <br /> +AxLxNc ADDPfss / AA L CITY Ste- STATE ZIP <br /> -NONE W%APSA/,CODE TYPE OP DUSINEIs <br /> //L — y6 E47�j(l ( 1 01 GASOLINE STATION ( 1 02 OTHER <br /> IVY.BIR Cf CONTAINEPS� RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> . 11 24 HOUR EMERGENCY CONTACT PERSON <br /> )AYS: NAY,EI LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME/LAST NAME FIRST) AND PHONE WIAREA CODE <br /> art c , S,RCoLca - 6 11-119 - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> :V DESCRIPTION <br /> L. ( ) 01 TAM( ( 1 02 OTHER: CONTAINER NUMBER <br /> 3. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1 ) UNKNOWN <br /> 1. CONTAINER CAPACITY: GALLONS l 1 UNKNOWN E. DOES THE CONTAINER STORE: I 1 01 WASTE I ) 02 PRODUCT <br /> °. DOES THE CONTAINER TORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 <br /> 01 UNLEADED 1 02 REGULAR 1 1 03 PREMIUM 1 1 04 DIESEL ( 1 05 WASTE OIL l 1 06 OTHER <br /> l CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( 1 CM 1 1 UNKNOWN <br /> 3. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULTI 1 ) 02 HON-VAULTED ( ) 03 UNKNOWN <br /> 01 DOUBLE WALLED Ste' 02 SINGLE WALLED l 1 03 LINED <br /> ).x1 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD l 1 OB BRONZE 1 1 09 COMPOSITE f 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN) ( 1 13 OTHER-- <br /> 3C04-070185 <br /> THER:3004-070185 PAGE i <br />