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STATE ID NUMBER <br /> • / y <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK / <br /> 1r 1 1 01 NEW PERMIT— — ( 1 OS RENEWED PERMIT 07 TAN)( CLOSED i 1 09 OELETV FROM FILE INO FEE) <br /> I 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE [NO SURCNARGEI <br /> I OWNER <br /> ,,,,,,yyyy <br /> NAY.t(COPoOR 1 N 7!u OR FUBI SC Aat NCYI PUBLIC AGENCY ONLY <br /> 1 1 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> STRtE7 ACORESS CITY ESTATE II Sl <br /> �A- 7� <br /> II FACILITY <br /> FACILITY NAME <br /> Of AIfY/FORM[N,SIN[RV ISO° <br /> STREET AOCICSS NEAREST CROSS STREET <br /> C:TY �� N p/��✓I ) C Cl lJ COUNTY � ==P <br /> MAILING ADORCSS 0 O t 1 I CITY ����� STAT ==°Y313 7/� <br /> PHONE W,AREA CODE V TYPE Of bustNlss <br /> 1 1 01 GASOLINE STATION 1 1 02 OTHER <br /> NVr6ER CF CONTAINER$ •VVAL AREAS ONLY TOWNSHIP RANO! SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: 1AMEIL11T�NAAME FIRST) AND PHONE W/AICCA `CODE <br /> NIONTS: NAME(IAST NAME FIRST) ANO PHONE W,APEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 1 01 TA11K 1 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEI: YEAR MFG: C. YEAR INSTALLED 1 I UNKNOWN <br /> 0. CONTAINER CAPACI Ty.. vv �'y/GALL014S 1 1 UNKNOWN E. DOES THE CONTAINER STORE 1 1 01 WASTE f 1 02 PRODUCT <br /> .._.__.—_ -- -L._ <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES 1 1 02 NO IF TES CHECK APPROPRIATE BOKIESI: <br /> 1 1 Ol UNLEADED 1 1 02 REGULAR 1 1 03 PREMIUM 1 1 04 DIESEL ( 1 05 WASTE OIL l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICT.IIESS OF PPIMARY CONTATNMEIIT: 1 1 GAUGE 1 1 INCHES ( I CM 1 1 UNKNOWN 1 <br /> i <br /> I8. 1 1 01 VAUL7E0 (LOCATED IN AH UNDERGROUND VAULT) 1 1 O<' NON-VAULTED ( 1 03 LRIKHOWN <br /> IC. ( 1 01 DOUBLE W1LLEO ( 1 02 SINGLE WALLED l 1 03 LINED <br /> D. 01 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> / 1 1 06 ALUMItAiM ( ) 07 STEEL CLAD 1 1 08 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UIIKNOW11 1 1 13 OTHER: <br /> HSC04-070185 -- ----_— --- PAGE 1 <br />