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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK`- _- <br /> 1- NEW PERMIT C 1 05 RENEWED PERMIT l 1 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEET <br /> 1'1) 02 CONDITIONAL PERMIT -(-) 06 AMENDED PERMIT- ( } 09 MINOR CHANGE (NO SURCHARGE) - -�- -_- <br /> I OWNER ---- <br /> f -- .__. - -_..__-_-- --------•--------------�-- --- �PUBLIC AGENCY ONLY <br /> r..rE c P�CPRTION.INCIVIDL1iL R PUS LIC A ENCY � � 1 01 FED 1 1 02 STATE C .1 03 LOCAL <br /> _. _ ._ _.-_..�]__ <br /> LCITY �/fJ ST E PIP <br /> S7 P-ET_T 5 ,��7/! L" 4•� /� r "-`r/ <br /> II FACILITY _ _- <br /> ___-__._._._.--_ --- - � � EALER/FOPEMEN/SVPEPVI P <br /> FACILITY N.�E Ot <br /> C <br /> STREET FDC"ESS ! �f (' NEAREST CR 33,77 <br /> E <br /> ------ - -- - 7 IffrAll <br /> _CU / ZIP /P�F <br /> CITY r <br /> f � <br /> - --' CITY - STATI _ ZIP S ��p41 <br /> MAItING AD <br /> DHOf+! W•ArE• CARE i TYPE OF BUSINESS - ----- <br /> _ ( 1 01 GASDIINE STATION C 1 42 OTHER — <br /> --- -- --- PUPAL AREAS ON TDW`ISHiP PANGS SECTION <br /> iit1MSEP CF GDNTAIN PS �-. _ -----„-----.--_ <br /> III '14 HOUR EMERGENCY CONTACT PERSON -- -- - _------ _ <br /> 1 -- <br /> ;Df_IPST )AND PHONE W/APE CODE NIGHTS: NAnE[LAST NAM FIRST] OND RHONE W�"AjPER CODE <br /> DAYS: NAMEfLAST NAME <br /> �� � �•��r �f -�L.�e���--- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> i <br /> �A. t6_03 TANK ( 102 OTHER CONTAINER NUMBER <br /> I _ -- <br /> j YEAR MFG= C. YEAR INSTALLED ;�?,!JNKNDWN <br /> B. MANUFACTURER (IF APPROPRIATE)! _ TOOT TOOT -' <br /> D CONTAINER CAPACITY 7^ GALLDNS E. DOES THE CONTAINER STORE: ( I O1 WASTE _La D2 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? P<1, 01 YES [ 1 02 NO IF YES CHECK APPROPRIATE BOXCES1= <br /> ( 1 41 UNLEADED 1 1 02 REGULAR [ 1 03 PREMIUM 01 04 DIESEL_ 1 1_05 'WASTE OIL (1-1 06 OTHER----_._.�.._------TOOT-- <br /> V CONTAINER CONSTRICTION--- �— W-- � — -�-- -- ---- <br /> A. THICKNESS—OF PRIMARY CONTAINMENT— �— 1 1 GAUGE 1 1 INCHES t 1—CM— 1NKNOWN ^—_ — ---� <br /> - ---TOOT - - <br /> B. f V01 VAULTED ILOCATED IN AN UNDERGROUND VAULT ( 1 02 NDN-VAULTED )/-J 03 UNKNOWN TOOT <br /> �C. i 141 DOUBLE 141LLEO f 1 02 SINGLE WALLED I t 03 LINED <br /> r•--.._—�. ----_. ._`----...__..--_—_.__�_.._--�---TOOT------ <br /> D. 111 CARBON STEEL t ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE C 1 a5 CONCRETE <br /> { Y 06 ALUMINUM 1 1 07 STEEL CLAD ( 1 06 BROIIZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 13 OTHER, <br /> — PAGE 1 <br />