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! • STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERA E UNDERGROUND STORAGE TANK <br /> ( O1 NEW PERMIT ( 1 OS RENEWED PERMIT l 07 TANK CLOSED <br /> 9 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( 1 04 MINOR CHANGE IND SURCHARGE) <br /> I OWNER <br /> PUBLIC AGENCY ONLY <br /> NAM�E`�(C��OPPORATION,INOIVIDUAL OR PUBLIC AGENCY) ( ) 01 FED ( 1 02 STATE (.1.4-03 LOCAL <br /> .J(Ml SO0. (A.l L©(A.h•F - STATE ZI/P��q <br /> CITY / /`J[17' <br /> STREET Pr­��� -�- <br /> II FACILITY ///� <br /> DEALER/FOREMEN/SUPERVISOR �/7 /-`Q F"r POO <br /> FACILITY NAME lYll S <br /> l Q <br /> NEAREST CROSS STREET <br /> RADe-l(&I ' . <br /> Cl!, k_/ <br /> ZIP <br /> COUNTY <br /> CITY `({,./ �y, Joa ul <br /> 5�-��"� STATE ZIP <br /> Cc Al Cy/ D <br /> MAILING ADDRESS CITY <br /> (_/�--G C 7 7 <br /> � O O <br /> TYPE OF BUSINESS <br /> P HONyPPEP c�oT 3 02 OTHER <br /> l ) O1 GASOLINE STATION (x1 <br /> � <br /> NUMBER OF CONTAINERS PVP,AI AREAS ONLY TOWNSHIP <br /> RANGE SECTION <br /> ---6 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> {�5T1 CA.NO.,yP/HONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) <br /> pAND <br /> ./P HONE W/APR EA CODE <br /> DAYS NAI ITS AND <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> CONTAINER NUMBER = <br /> A. (6 01 TANK ( ) 02 OTHER: <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C.�YEAR INSTALLED (W UNKNOWN <br /> 0. CONTAINER CAPACITY: Stra GALLONS W UNKNOWN E. DOES THE CONTAINER STORE: (XI 01 WASTE ( 102 PRODUCT <br /> 1 YES f 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> F. GOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIl ? l�0 <br /> f ) O1 UNLEADED ( l 02 REGULAR ( ) 03 PREMIUM f ) 04 DIESEL X05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM ml\enlr UNKNOWN <br /> B. f l Ol VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( 03 UNKNOWN <br /> C. ( 1 O1 DOUBLE WALLED UC) 02 SINGLE WALLED l 1 03 LINED <br /> D ( I01 <br /> CARBON STEELINUM lO)05OB <br /> 02 STAINLESS <br /> SlE)LI BRONZEFIBERG09SCOMPOSITE POL)V10YNON-METALLICCHLORIDE <br /> 05 COCRETE <br /> ( ) <br /> 06 <br /> X12 Ut1KNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />