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Ay / `Wl S%,,04 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> TA O1 NEW PERMIT l 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED <br /> 1 ) 09 OELETC FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 OB MINOR CHANGE IND SURCHARGE) —_ <br /> I OWNER - <br /> NAr.!(COPPORATION•INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> — O1 FED 1 1 02 STATE 1 1 03 LOCAL <br /> CZ TY STAT£ ZIP <br /> STREET AC�RlSS T/ c- �� �F"� 'Z <br /> -----�2 7 SZ> GV • �T y® / C�6� 777 b J <br /> II FACILITY <br /> FACILITY NAV DEALER/FOPEMEN/SVPERVISOR <br /> /vI&,C <br /> STREET ADD-ESS NEAREST CROSS STREET <br /> CITY COUNTY - ZIP 3 <br /> MAILING OGRESS CITY STATE ZIP <br /> PHONE W%AFfA CODE =PURALAPEAS <br /> NESS <br /> O S ' OLINE STATION �02 OTHER <br /> NUMBER CF CONTAINER/S/ TON NSNIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS'. NAME(LAST NAME FIRST) AND PHONE W/APIA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> q c'QI — &39-- S 7 _0 Ca 4hze re-e—k - ffs-- 79 0_ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> 's A. 01 TA10C ( 1 02 OTHER: CONTAINER NUMBER / <br /> B. MANUFACTURER (IF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: f9U GALL014S 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE :Sd 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OILP 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BO%(ES1: <br /> 1 1 O1 IP.tLEA0E0 ( 1 02 REGULAR ( ,�03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICF.NESS OF PRIMARY CONTAINMENT ( 1 GAUGE ( 1 INCHES l I CM N,4 UNKNOWN <br /> 0. 1 1 01 VAULTED ILOCATEO IN AN IRtOERGROUtM VAULT) >-PO2 NON-VAULTED ( 1 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE WALLED 1>42 SINGLE WALLED 1 1103 LINED __- <br /> 0, t 1 01 CARBON STEEL l l 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> I ( 1 06 ALUMINUM 1 ) 07 STEEL CLAD 1 1 OB BROIIZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOW)) l 1 13 OTHER: <br /> PAGE 1 <br /> H3C04-070185 <br />