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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEN PERMIT ( 1 OS RENEWED PERMIT ( 1 07 TANK CLOSED l ! 09.OELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 00 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NA►:ICORPORATION. IVIDUAL OP PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED 1 1 02 STATE ( 03 LOCAL <br /> TATE <br /> IP <br /> s.1 � �,��-° ' ----=�2-- �I '-BOG Ic S� — Zs a cam, <br /> TOtET <br /> II FACILITY <br /> FACILITY NA::E DEALER/fOPEMENISUPERVISOP <br /> sviv IF7/o el <br /> STFEET ACO'ESS Oct NEAREST CROSS STREET <br /> CITY COU" ^� ZIP <br /> T ,alp- <br /> 1/ DJ �J 'rel <br /> MAILING ADDRESS CITY STATE ZIP <br /> CAA Q 0/6 <br /> PMOL! W-ACEA CODE TYPE Of BUSINESS <br /> C>Ct (tiol 01 GASOLINE STATION l 1 02 OTHER <br /> NUPBEP CF CONTAINERS — PUPAL AREAS ONLTOWNSHIP RANGE SECTION <br /> Y <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DA( <br /> H�r,Ef LAST/—NA )PST I AH r��E W/A`Ei O wl/ NIGHTS:�) /NAMl(l,A/ST NAME PIRST IcAN�O PNO�NE WfAPEA CODE - <br /> 177 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. Q4 01 TAW ( 1 02 OTHER: CONTAINER NUMBER <br /> S. MANUFACTURER (IF APPROPRIATE?: Lt-N ' 7 1 D j� 7�( 1 UNKNOWN <br /> �'( '� YEAR MFG: 1� 111 - -- -----YEAR INSTALLED <br /> ---------- - <br /> 0. CONTAINER CAPACITY:gOOC> GALLONS 1 1 UNKNOWN E. GOES THE CONTAINER STORE: 1 1 01 WASTE l-If 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> pG1 01 LP)LEADED ( 1 02 REGULAR l 1 03 PREMIUM ( 1 04 DIESEL ( 1 OS WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. T)!ICYNESS OF PP.IMARY CONTAINMENT: 1 ) GAUGE ( ) INCHES 1 1 CM CTC) UNKNOWN <br /> 'B. ( 1 01 VAULTED (LOCATED IN AN UtMERGROUND VAULT) ('SFJ 02 NON-VAULTED 1 1 03 UNKNOWN <br /> 1 <br /> ,C. 1 1 01 DOUBLE W1LLE0 (() 02 SINGLE WALLED l 1 03 LINED <br /> �0. /c1 01 CARBON STEEL 1 1 02 STAINLESS STEEL ( 1 03 FICERGLASS t ) 04 POLYVINYL CHLORIDE ( 1 OS CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAU 1 1 08 BRONZE 1 1 OV COMPOSITE l ) 10 NON-MET4LLIC <br /> ( 1 12 I1t;KNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> i i <br />