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STATE ID NUMBER b3 G <br /> V-4 APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> y—i 01 um—put= f 1 05 RE14EWEO PERMIT ( ) 07 TANK CLOSED d ) 09 OELET€ FROM FILE (NO FEE ) <br /> ( 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> ?14ME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Cl FED r 1 02 STATE ( 1 03 LOCAL <br /> STREET AO'1RE55 JCITY STAT' ZIP <br /> II FACILITY <br /> FACILITY NAME ` OEALER/FOREMEN/SUPEPVISOP <br /> STREET ADOMESS NEAREST CROSS STREET <br /> 2-d a . , j ., <br /> CITY COUNTY <br /> _ ' ZIP <br /> .I MAILING ADDRESS CITY -Tse, <br /> TATE ZIP <br /> J r' CrJ'240 4' <br /> PHONE WlArE4 CODE TtiPE CFBUSINESS <br /> -2!;LT: [(�jpQ f 1 O1 GASOLINE. STATION P.1 02 OTHER <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> IIF 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEtLAST NAME FIRST) AND PHONE W/APER CODE NIGHTS: NAMEILAST NAME FIRST) AND PHONE WiAREA CODE <br /> r <br /> 6 _4A_LT/L- � v Ya ra tt/ j`2 , 19 7 'i/7 5)-- g <br /> COMPLETE 'THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> a; A. <br /> PCA O1 TANK f 1 02 OTHER CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEI= TGICfCCs7rJ s4�6,�s (ES �,I, �AR MFG:/� C. YEAR INSTALLEDgj� I 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: /,000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: (NK01 WASTE f ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? IL,* 01 TES 1 ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f 1 01 UNLEADED l 1 02 REGULAR { ) 03 PREMIUM ( 1 04 DIESEL ( L 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PPIMART CONTAINMENT: fQ) GAUGE ( J INCHES ( 1 CM f ) UNKNOWN <br /> IS. ( 1 01 VAULTED ( LOCATED IN AN UNDERGROUND VAULT) (j,41,02 NON–VAULTED f ) 03 UNKNOWN <br /> C. C 1/r 01 DOUBLE WILLED i 1 02 SINGLE WALLED { 1 03 LItIFD <br /> D. I� 01 CARBON STEEL f ) 02 STAINLESS STEEL ( 1 03 FICERGLASS f ) 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br /> f ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BROtIZE C 1 09 COMP05ITE ( ! 10 NON–METALLIC <br /> i ) 12 UNKNOWII ( 1 13 OTHER: <br /> H5v04-070I85 -- � PAGE ' <br />