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STATE 10 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STOgAGE ;jANK ; { <br /> 1,1 Ol MEM PERMIT-i I ' l 1 OS RENENEO PERMIT I ) 07 TANK CLOSED .,.I ),r09 OELETC FROM f,94-1t.10 FEE l <br /> 1 1 02 CONDITIONAL PERMIT f 1 08 AMENDEO PERMIT t 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMtICORPORATION,jNO2V20VAl OR 1UOLtC AOc Y) PUBLIC AGENCY ONLY <br /> O1 FED t 1 02 STATE t a. 93 LOCAL <br /> >K "lRttT AEtNRtif ' ,1 CITY STATE 22 <br /> AA, <br /> II FACILITY <br /> FACILITY NAM DlAI[R/FOPlMEN/SUJPERVISOR r, <br /> STREET AODttSS NEAREST CROSS STREET <br /> CITYCOUNTY ZIP <br /> MAILINO AOOPESSCITY STATE ZIP <br /> ( rrr <br /> PHONE H%AetA `Coot 1 TYPE�P DUSINtSf , - <br /> W 01 GASOLINE STATION UI-02 OTHER <br /> NUr.OER CF CONTAINERS RURAL AREAS ONLY TOWNSH;P ►ANC! SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NA-..11LAST NAME FI►ST) AND PHONE W/ARCA COOL NIONTS: NAME(LAST NAME FIRST) ANO PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 01 TANK ( 1 02 OTHER) CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE 1: YEAR MFG: C. YEAR INSTALLED_ ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY:IdQOG GALLONS t 1 UNKHOW24 E. GOES THE CONTAINER STORE: ( 1 O1 HASTE ( :02 PRODUCT <br /> F. ODES E CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 6 1 01 YES t 1 02 NO IF YES CHECK APPROPRIATE BO%IESI: <br /> tLf 01 L41LEAOCO ( 1 02 REGULAR t 1 03 PREMIUM t 1 04 DIESEL l 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICY.HESS OF PP.IMARY CONTAINMENT: ( 1 GAUGE t ) INCHES t 1 CM ( i�( UNKNOWN <br /> S. t 1 01 VAULTED (LOCATED Itt AN UNOERGROUtIO VAULTI '( 02 NON-VAULTED ( ) 03 (RIKHOWN <br /> �C. (N O1 DOUBLE W A L L E 0 (+ ) 02 SINGLE WALLED i 1 03 LINED _ -- <br /> 10. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL (i O3 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE t l 05 CONCRETE <br /> ( 1 06 ALUMINUM l 1 07 STEEL CLAD ( 1 08 BROtIZE I ) 09 COMPOSITE ( ► 10 NON-METALLIC <br /> 12 UIIKNOWti ( 1 13 OTHER: --- ---- —�--- ,-- -- - -- ---'-- -.'_.- <br /> H3C04-070185 PAGE 1 <br />