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1 lxl4b STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 01 NEW PERMIT l 105 RENEWED PERMIT 07 TANK LOSE ( l 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ) 00 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY' PUBLIC AGENCY ONLY <br /> 1 ( 1 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br /> STREET ADII; a 1.1G.- <br /> J— CITY STATE ZIP <br /> �/i <br /> WAL C* <br /> II FACILITY <br /> FACILITY NAME DEA R/FOREM N/SUPERVISOR <br /> 5 <br /> STREET AODPESS NEAREST CROSS STREET <br /> CITYCOUNT ZIP <br /> MAILING ADDPESS CITY STATE ZIP <br /> 91 L a C C <br /> PHONE W,APEA CODE TYPE OF BUSINESS ` <br /> ( ) 01 GASOLINE STATION 02 OTHER! / <br /> NU"EP OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEf LAST NAME FIRST' AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> �Y�F91T �7'S�799/ li#iit6 762' SI?a <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): - YEAR MFG' C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: 6-0c) GALLONS ( ) UNKNOWN E. DOES �T/HE CONTAINER STORE:it 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINE TORE MOTOR VEHICLE FUEL OR WASTE OIL ? JX,1_01 ES f 1 02 NO IF YES CHECK PPR IATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL 05 WASTE OIL ( 1 06 OTHER ,,�O,,((���tPR <br /> �..-�. <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM 00 UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) T-,-02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. f ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED f ) 03 LINED <br /> D. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL f ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />