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\- <br /> • L .TATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 01 NEW PERMIT ( 1 05 RENEWED PERMIT l 1 07 TANK CLOSED l 1 09 DELETE FROM FILE (NO FEEI <br /> 1 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( 1 00 MINOR CHANGE (NO SURCHARGE) <br /> 1 OWNER <br /> {(NAM'_ICOP P OR AT TON.INO IVIDUA L OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> (_ 1 O3 FED f 1 02 STATE 1 1 03 LOCAL <br /> k{S Ti EET ACOPESS -- CITY STATE ZIP <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMENISUPEPVISOP <br /> Ro7L fl o a�F2 S�/� Ste, fTF�f /f/FFF�2 <br /> STREET ACC-ESS NEAREST CROSS STREET <br /> CITY <br /> COUNTY <br /> ZIPS170j— <br /> MAILING <br /> o 7oc c�7'dH J/AAs' (/o/fa"� X/ 7 .S' <br /> MAILING ADDRESS CITY STATE ZIP <br /> -- Pv Wale1,� ST�r�To v �9 9S z/3 <br /> PHONE W-AeE.7'7,7—E 1'Ldf-Z6/d TYPE <br /> 01 GASOLINE STATION bg:/ 02 OTHER <br /> tAlY6EP CF CONTAINEPSPVRAL AREAS ONLY TONNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> iCAYS: NAr,Er L45T NAME FIRST) AND PRONE N/APER CODE NIGHTS: NAMEILAST NAME FIRST) AND PHONE W/APEA CODE <br /> LKiE6fE/Z� Srt<yE - - ?oy_rf65=Z6ib � <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> MA. 1 1 01 TAIIK 02 OTHER: CONTAINER NUMBER <br /> B. MA14UFACTUPER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED/1'" ( 1 UNKNOWN <br /> D. CONTASkER CAPACITY: / GALLONS 1 LLWNCWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (,Kot PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WAST OIL ? r,401 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> 1 1 01 UNLEADED l 1 02 REGULAR l 1 03 PREMIUM 04 DIESEL 1 1 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION _ <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 4'� /'rCfj/ ( 1 GAUGE ( 1 IIICHES 1 I CM I 1 UNKNOWN - —B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) L,6 02 NON-VAULTED ( > 03 UNKNOWN <br /> 1C. III 1 01 DOUBLE WILLED 1 02 SINGLE WALLED 1 1 03 LINED <br /> 0. I 01 CARBON STEEL l 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 1 <br /> -1-0-6- <br /> ALUMINIUM ( 1 07 STEEL CLAD 1 1-08 BRONZE I ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UNKNOW)) l 1 13 OTHER: <br /> 113004-0:0185 PAGE 1 <br />