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1 <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 NEN PERMIT 1 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED 1 1 09 OEIETC FROM FILE (NO FEE) <br /> 1 1 02 COf10ITIOHAL PERMIT 1-1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE IND SURCHARGE) —_— �: <br /> I 01•INER <br /> NAr.E(COff09QA..TTIION,INOi V�I(}/jUA1 OR PVDI2C AOCNDYI /r PUBLIC AGENCY ONLY <br /> 5..o ` Q-�(_O ' t /r�/L P(• A / L{ `_.O m�Q/✓K 1 1 Ol FEB 1 1 02 STATE 1 1 03 LOCAL <br /> STATE <br /> STPEETACOYESI- ^""r - - CIITv O <br /> II FACILITY <br /> FACILITY NAME_ A .43 4 Of AIfP�FOP MFNYRLPEPV(,r- a — <br /> STREET ACL" NEAPE�QOSS STPEET <br /> CITY 1 - CO VY _ ZIP fi <br /> MM=MING ACD,p o1 ( CITY STATE <br /> PXON• W'A•/IF�/1 TL Of DUS INESS '`�N_ ✓\. 1' , / 7- <br /> 1 ,01 GASOLINE STATION 1 1 02 OTHER <br /> Nurago Cf CONTAINEPS 3 PUPAL APEAS ONLY TOWNSNI► PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAY,lIIAST NAME FIPS 1 ANO PXONf /APCA CODE NIONiS: NAM[ lA T NAM! fIP5T1 ANO PNONf 4/AREA COD! / <br /> �Sou�ar ( c11� h�DT� 4aa -1 88 <br /> Ile(-b �e:EraVTJC c - ;©d <br /> s <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> if A. Ix TANM 1 1 02 OTHER: CONTAINER NUMBER <br /> 77 <br /> B. MANUFACTURER (IF APPROPRIATEI: YEAR MFG: C. TEAR INSTALLED /�'z 1 1 UNKNOWN <br /> D. CONTAINER CAPACITY: VVV GALLONS - UNKNOWN E. DOES THE CONTAINER STORE-- I 1 01 WASTE ()6 02 PRODUCT <br /> F. DOES THE CONTAINER"'STDRE HOTO� FUEL OR WASTE OIL ? ()4 01 YES 1 02 NO IF YES CHECK APFROPRIA E BOKIESI: <br /> I 1 01 UNLEADED 02 REGULAR 1 ) 03 PREMIUM l 1 04 DIESLL, 4 1 OS WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION l <br /> A. THICKNESS OF PRIMARY CONTAINMENT: SIA 2 sj I 1 GAUGE I LACHES 1 I CM 1 1 UNKNOWN <br /> B. I 1 01 VAULTED (LOCATED VIII AN IUIOERGROUIIO VAULT) t /A 02 NON-VAULTED 1 1 03 (UNKNOWN <br /> IC. ( 1 01 DOUBLE WILLED 1 X 02 SINGLE WALLED 1 1 03 LINED <br /> 0. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL t_) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE I I OS CONCRETE <br /> 1 106 ALUMINIUM 1 1 07 STEEL CLAD 1 1 OB BR0ItZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 UIIKNOWII 1 1 13 OTHER_ <br /> I/3C04-070105 PAGE 1 <br /> ��loof <br />