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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 01 NEW PERMIT ( 1 OS RENEWED PERMIT 1 ) 07 TANK CLOSED 1 1 09 DELETE FROM FILE (NO FEE) <br /> f 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER _ 1tJ -usf/Z� <br /> NAY.E(COPPORATION.INCIVIDUAL OR PUBLIC AGENCY) / PUBLIC AGENCY ONLY <br /> �A/AF4 .4 e. Pat- �/jF7fL ( 1 01 FED 1 ) 02 STATE 03 LOCAL <br /> STREE-TF ASC^RISS CITY STATE ZIP <br /> t ---'-L��E. _F�r�1oA,rj 57 _ s'7`oc,E�o.✓ --- G'`� 9s2d� <br /> II FACILITY <br /> FACIIIT 4ME DEALER/F CP E M E N�SVPEPVISOP <br /> (�( g2(-7dN t'dOp /�.GS�iFi�l�+�Rf-TAle- —�.�L, DE1� <br /> FEET AOD'ESS NEAPES CROSS STREET <br /> �A ITY COU TY ZIP <br /> — O,I�oN GA ��N <br /> To-P, 95zos <br /> iy MAILING ADDRESSCITY ST ZIP <br /> '^ <br /> -- 3 O 5-ToGy/G7o9SZo/ <br /> PHONE W,AREA CODECp L.l TYPE OP BUSINESS <br /> / i 1 01 GASOLINE STATION IXi 02 OTHER <br /> NUMBER CF CONTAINE=S PUPAL AREAS OHLY TOWNSHIP RANGErN <br /> SECTZ OI{ - <br /> -- - 1 - '---- ----- -- - IJ <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> [DAYS: NAP.E(JAST NAME FIPST) AND PHONE W/APEA CODE 7� NIGHTS: NAME(LAS_NAME FIRST) AND PHONE <br /> PODE <br /> Llrl 4-1 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1-A 01 TANK ( -1 02 OTHER: _ _ CONTAINER NUMBER / <br /> B <br /> . MANUFACTURER (IF APPROPRIATE): �/NK _ YEAR MFG: C. YEAR INSTALLED (XI UNKNOWN <br /> CAPACITY: GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 1 1 02 PRODUCT <br /> DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (� 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 ) 01 UNLEADED l 1 02 REGULAR ( 1 03 PREMIUM (X 04 DIESTIL 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE f ) INCHES 1 1 CM lkr UNKNOWN <br /> IB. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l>(1 02 NON-VAULTED ( 103 UNKNOWN -- - -_ <br /> C. ( 1 01 DOUBLE WILLED 1 1 02 SINGLE WALLED 1 1 03 LINED <br /> (F. (�O1 CARBON STEEL l 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 OS CONCRETE <br /> 106 ALUMINUM l 1 07 STEEL CLAD ( 1 08 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER: <br /> H5C04-070185 PAGE 1 <br />