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STATE ID NUMBER <br /> APPLICATION ,FOPERMIT TO OPERATE UNDERGOND STORAGE TANK <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> 2 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( 1 0$ MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPv RATIO N.INDIVIOV L OR P LIC AGENCY) PUBLIC AGENCY ONLY <br /> l 1 01 FED 1 ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS 'C-. ' / 7 L/4�/V S 7 C TY��� Al ST Tl: ZIP 6_ . <br /> II FACILITY N /gid <br /> S c Lon S <br /> FACILITY NAMEO L) <br /> DEALER/FQ$EMEN/SVp ERVISOR <br /> STREET ADD?ESS !` r 14AJ -S� <br /> NEAREST G/R�^OS�T�PUE E/G]T <br /> G` ST7 <br /> CITY �Vc C�f_!ILJ COV TV �v� � 2IP <br /> MAILING ADDPESS ^ /J " CITY ^_ / STAS E �� <br /> IIP� ( <br /> ax <br /> PHONE W%AvEA CODE-�v yL'`� TYPE OF BUSINESS <br /> I(`,JLfJ\ ,NL'/ G.(Np•• <br /> Q a 3 ( ) O1 GASOLINE STATION )LS2 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME(I;S JJArye��T) ANDo NONE/AREA/CZO/ R� NI���,ME(LAST O� NAME FIRST) OAND�PHONE <br /> �9W/APEA CODE <br /> �� <br /> 1 Y.IG /f�/O(G/ o — �Y•CJ /L/CnJ?- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( ) 01 TANK 40 <br /> 2 OTHER) CONTAINER NUMBER Z <br /> B. MANUFACTURER (IF APPROPRIATE); fie6J k)94104 S YEAR MFG: / G C. YEAR INSTALLED ) ) UNKNOWN <br /> !o d <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WST OIL ? Q ' 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( ) 01 UNLEADED ( 1 02 REGULAR ( ) 03 PREMIUM 04 DIESEL f 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> a <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE f ) INCHES ( ) CM l ] UNKNOWN <br /> B. 1 l '01-VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 2 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 11 01 DOUBLE WALLED ( OF SINGLE WALLED ( 1 03 LINED <br /> D. (�) O1 CARBON STEEL ( ) 02 STAINLESS STEEL 1 ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> l 06 ALUMINUM ( 1 07 STEEL CLAD 1 1 OB BRONZE,,_ ( .) .09 COMPOSITE ( ) 10_NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE <br />