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STATE IO NUM3EC <br /> APPLICA'110N FOR PERMIT TO OPERATE UNDERGRDUND STORAGE TANK <br /> ) 01 NEW PTRI:IT t 1 05 RENEWED FLP.)iIT ( ) 07 TAt D( CLOSED ( ) 09 DELETE fPGH FILE WO FEE 7_7 <br /> "T,;MTIONAL PERMIT ( 1 06 Arl0'.)E_D PERMIT ( ) OD MINDR CHAIIGE RIC SURCHARGE) 1111 <br /> I OONEP, <br /> 1?,aME1CO7P0/?F.T,ICK. JIVIDUAL OR FL'DLIC GEKC1') I _ PUBLIC AGENCY ONLY <br /> ,0 C'�T� l 1 Ol FIG ( 102 STATE ( 1 03 LOCAL <br /> IST VLET AODPESS - CIT)' STATE ZIP <br /> �a11� _ S , � �buJQt' few S 00 � I <br /> 1I FACILITY <br /> r <br /> iF;,_II STY I:tME Arco -�I / DE4LER/FOREVPEFVISO.j���` n <br /> i STPEET ADDL'ESS NEARE T CROSS STREE <br /> I -c a--L <br /> iCT.TYCOU Y SIP <br /> S-�-o 1�— <br /> iC-ILIgg ADRES CI STATE II <br /> iFXONEt Wl/'ARE1 COO- TYP OF BUSINESS <br /> lel ! Il �3 — �eZ_�_ (A 01 GASOLINE STATION ( ) 02 OTHER <br /> —i--DER OF CCNTAJI;EPS /L RVRAL AREAS ONLY TOWNSHIP RANGE SECTION --� <br /> 1II 24 HOUR EMERGENCY CONTACT PERSON <br /> rCSYS: Nf.M•(;AST .nEF� �I: A1'C PXO!:E W/A)REA4 CEDE f:IGHTNAME(y A,ST NAME FIRST) AND FXQ.�OT PE� <br /> !F <br /> yMl l (�a� /t7—t^, a �V�- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORI4 FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> r <br /> IA, i ) ( ] 04 OTHER: _ CONTAINER NUMBER <br /> i 1 <br /> iB. M NUFALTURER (IF APPROPRIATE): YEAR MFG*• C. YEAR I14STALLED p ( ) UtO:NOWN i <br /> i <br /> ID. COtJTAINER CAGALLONS ( ) UNKNOWTI E. DDES THE CONTAINER STORE: ( 7 Oi WASTE ( 02 P'i'OOUCT_ � <br /> � '�,t "' I F DES THE CCUTAIRER STORE MOTOR VEHICLE' FUEL OR WASTE OIL ? y.LyyX{S I 1 02 NO IF YES CHECK APPROPRIATE BOX(ES); <br /> 1 0 _£kb7D ( 1 02 REGULAR ( ) 03 PREhIUM ( 1 04 DIESZLl 105 WASTE OIL Ob OTHER i <br /> I <br /> V CONTAINER CONSTRUCTION <br /> I <br /> iA. THICKNESS OF PRi75ARY COi7TAIK TENT: O' ,2 SO t 1 GAUGE JqUZ4ES ( ) CM ( 1 UNKNOWN <br /> E. l ) 01 VAULTED (LOCATED IN AN UNDERGROUND.VAULT) (x 0 IGt:-VAULTED ( ) 03 UNKNOWN <br /> {C. l ) 01 DOUBLE WALLED ( LE WALLED f ) 03 LINED <br /> ,D. t 1 01 CARSC:: STEEL ( 102 STAItUES`: L)EEL (X 03 F BERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) CS AL"!IN1.111 l 1 D7 STEEL. C;.i,P ( 7 o8-BQe4Tn 09 COMPOSITE ( 1 10 HON-MET'ALLIC <br /> I f ) <br /> 12 U:n7:0;S( ( ) 13 OTHEC: <br /> PAGC 1 <br /> FSC04-070185 <br /> t <br />