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I <br /> ' . STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE,iTANK •, <br /> ( 1 01 NEN PERMIT ( 1 05 RENENEO PERMIT 1 1 07 TANK CLOSED 1 1 00 OELETQ:FROM F7IJ (HOFEET1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 00 MINOR CHANGE (ND SURCMARCEI _V1 <br /> \iTP.L-HEALTH <br /> I OWNER <br /> NAnt(coPPoRATION.1M01VIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 4 S o ,v f ( 1 01 FED 1 ) 02 STATE l -1 03 LOCAL <br /> ORlIt CITY STATE <br /> [TP[[T AO2IP <br /> 3835 F' - YI'IR � n/ P-C) . (39>)e- 5523 rS7ocK-role �. e-fl, NQS f>S <br /> ' II FACILITY <br /> FACILITY NAME DEALER/f OOEMEN/SUPERVISOR <br /> WATE_RLPKET r3 R q /,I .-r LL <br /> STREET ADO-ESS NEAREST CROSS STPEET <br /> / OV/ S £ WATfRLOo CaA& sT061C <br /> CITY COUNTY IIP <br /> 57-ockr0 s7-oAau1A/ os <br /> MAILING ADDRESS CITY STATE IIP <br /> PHONE W,APEA CODE TYPE Of BUSINESS <br /> 709- ?3/- 61,77 (✓f 01 GASOLINE STATION 1 1 02 OTHER R K I( ,- T <br /> E01 COHTATNEPS RURAL AREAS ONLY TOWHSND RANGE SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEILAST NAME FIRST) AND PHONE N/APEA CODE NIONTS: NAMEILAST NAME FIRST) AND PHONE W/AREA CODE <br /> V�Nai+rl / 13kady - - ?31 -(/ 0-7 5 /1 m E ----- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> F <br /> A. (1/1 01 TANK ( 1 02 OTHER: l) !E' S C L CONTAINER NUMBER / <br /> B. MANUFACTURER (IF APPROPRIATE): rti u K'up✓VL/ YEAR MFG: C. TEAR INSTALLED ( "1 UNKll0M <br /> 0. CONTAINER CAPACITY: IO�o F 0 GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE* 1 1 01 HASTE 02 PRODUCT —_ <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (VI 01 YES l 1 02 NO IF YES CHECK APPROPRIATE SOXIESI: <br /> 1 I 01 UNLEADED ( 1 02 REGULAR l 103 PREMIUM (vi 04 DIESEL l 1 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> I`rA. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE ( I INCHES 1 1 CM_(✓` UNKNOWN <br /> B. 1 I 01 VAULTED (LOCATED IN AN UNOERGRO(U(0 VAULTI '1 ) 02 NON-VAULTED 1 ✓f 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE NALLEO (VI 02 SINGLE WALLED 1 1 03 LINED <br /> D. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL I 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> ( 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 00 BRO((LE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 of 12 UNKNOWN l 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />