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. / • STATE I0 NUMBER I 1� <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK / <br /> Ir 1 1 01 NEN PERMIT 1 1 OS RENEWED PERMIT Ste, 07 TANK CLOSED 1 ) OV DELETC FROM FILE (NO FEE) <br /> I 1 02 COUOITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE IND SURCHARGE) <br /> I OWNER __ ------ <br /> NAMEICOPPORATIOM.INOIVIDUA4 oR USLIC AOENCYI PUBLIC AGENCY ONLY <br /> ���� 1 01 FED 1 1 02 STATE ( 1 OS LOCAL_ <br /> STPEII A00REss CITY ^� STATE ZI <br /> -- - -AL3L J /F/.� ''w' <br /> II FACILITY _ <br /> FACILITY NAME DCAI[R/IOPCM[N�SVPCPV SSOP <br /> STPEET AOC'ESS NEAYEST CROSS STPEET <br /> COUNTY ZIP ( � <br /> CITY JJ <br /> MAILING AOOPESS ,^ <br /> CITY Iryy/li _/ STATE ZIP <br /> PMoNE W•ACEA Coot _ TYPE of BUSINESS <br /> 1 1 01 GASOLINE STATION 1 1 02 OTHER <br /> NVreEP CF CONTAINECS 1 RUPAI APCAs ONLY : TOWNSNI► PANcc SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME)LAST NAME PIPST) AND PHONE W/APEA COOL NIOMTS: NAME(LAST NAME FIRST) No PHONE WIAREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION ——— <br /> A. 1X1 Ol TAMOC 1 1 02 OTHER: CONTAINER NUMBER f <br /> L1- I <br /> B. MAMAIFACTURER IIF APPROPRIATE): YEAR MFG: C. YEAR UNKNOWN <br /> INSTALLED _ l_1 <br /> 0. CONTAINER CAPACITY: �dDO GALLONS 1 1 ;;H:=EOOES HECONTAINER STORE: I 1 01 WASTE ( 1 02 PRODUCT <br /> F. ODES THE CONTAI14EP STORE MOTOR VEHICLE FUEL OR WASTE OIL ? I 1 O1 YES t 1 02 NO If TES CHECK APPROPRIATE BOX(ESI: <br /> I 1 01 UIILEADED ( 1 02 REGULAR l 1 03 PREMIUM l 1 04 DIESEL l 1 05 WASTE OIL 1 1 06 OIHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICf NESS OF PRIMARY CONTAINMENT.- -- - ----�1 1 GAUGE <br /> -I 1 INCHES ( 1 CM 1 1 UNKNOWN <br /> B. I 1 01 VAULTED ILOCATEO IN AN U0)ERGROUI0 VAULT) l 1 02 NON-VAULTEO-t_1 03 LAIKNOWN <br /> IC. 1 11 01 DOUBLE W%LLEO 1 1 02 SFIGLE WALLED 1 1 03 LIIIED <br /> D. fT) 01 CARBON STEEL 4-)-02 STAINLESS STEEL 1 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE I 1 05 CONCRETE <br /> �� ( ) 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 00 BRONZE I 1 OR COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWII 1 1 13 OTHER: -- -- <br /> .-_-_ __._-__-___-_-__._-_— PAGE 1 <br /> 11SC 04-010185 <br />