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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Ixl <br /> 01 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 04 DELETE' FROM FILE (NO FEEI <br /> 1 1 02 CGUOITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (N0 SURCHARGE) - __- <br /> I OWNER _-- <br /> N• (COP OP ON.INC VIDUAL OR PUBLIC AGENCY) -- PUBLIC AGENCY ONLY <br /> t ) <br /> 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STCEET AC7R,SS C.� --- CI7Y�r/� STwf� ZIp„�`�O� <br /> II FACILITY <br /> FACILITY NA,-.f - DEALER/F E �1111TIVI OP <br /> •-'A'..'.--'� -- - <br /> S T FEET FCL1OESS Ni<AEST CROS -� <br /> CITY - --- COUN .-�. ! ZIP <br /> 7�(;1 MA7!*NG ADDPESS CIT"�� r �, ) S /) ZIP <br /> �Ii/ <br /> PHONE WAVE• CODE TYPE CF BUSINESS ,� <br /> hcl_1142 y11r ( 1 01 GASOLINE STATION k1 02 OTHER <br /> NVPBER CF CONTAINEvS PUPAL APEAS ONLY : TOWfeSNIP =11 SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> 0YS: NAOOME( ST NAME FIPST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> .::it A. (XI 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE)= YEAR MFG. C. YEAR INSTALLED --- ("1 UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS t 1 UNKNOWN E. DOES THE CONTAINER STORE= ( 1 01 WASTE ( /�'u2 PRODUCT —� <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 ! 01 YES 1 ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)' <br /> (IX 01 UI=LEADED ( 1 02 REGULAR ( i 03 PREMIUM ( 1 04 DIESEL t ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE t ) INCHES ( i CM ILI-UNKNOWN -- -- <br /> 8. ( M 01 VAULTED (LOCATED Itl Atl UNOERGROUND VAULT) 'f—T 02 NON-VAULTED I ) 03 UNKNOWN - — <br /> �C- f 1 01 DOUBLE WlLLEO SINGLE WALLED 1 ) (13 LIHE0 <br /> D. l i 01 CARBON STEEL f ! 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE [ 1 05 CONCRETE <br /> S 1 06 ALUMINUM l 1 07 STEEL CLAD t ! 08 BRONZE I 1 09 COMPOSITE ( i 10 NON-METALLIC <br /> 11/f 12 UNKNOWN { 1 13 OTHER <br /> PAGE 1 <br /> H5L04-070185 <br />