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400 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK _ _1 <br /> q6_01 NEW PERMIT 1 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED l 1 09 DELETE FROM FILE (NO FEET <br /> 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER _ _ — <br /> HAHE,COPPCPATION, NDIVIDUAI OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> �����G ---- — - - _[PUBLIC <br /> Ol FEO 1 l 02 STATE ( 1 03 LOCAL <br /> - - - <br /> F{- <br /> CITY <br /> CITY��/J/��/ STATE 2IP <br /> lSTP!ET AD^ SS C f <br /> II FACILITY <br /> FACIL•TY NAME DEALER/FOPEMENISUPEPVISOP <br /> )c _ t �J <br /> S'FEET ADD-ESS NEAREST CROSS STPEET <br /> e .T„ �1 COUNT Yom. 2IP�y <br /> { rAILING ADDPESS CITY (r STATE ZIP t <br /> � <br /> prHON! W,AREA CODE TYPE OF BUSINESS C <br /> l <br /> 01 GASOLINE STATION f 102 OTHER _ <br /> 6Ur6lR CF CONTAINEPS PUPAL AREAS ONLY TOWNSHIP PANGS SlCTION--- — <br /> III 24 HOUR EMERGENCY CONTACT PERSON _ <br /> flOAYS: NAMEILAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAMEILAST NAME FIRST) AND PHONE WIAPEA CODE —� <br /> L& s �9�/731e --- ilu) �s�y5 835�3zo6 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> -`A. 1 1 01 TANK f 1 02 OTHER: CONTAINER NUMBER <br /> S. MANUFACTURER (IF APPROPRIATE): YEAR MFG C. YEAR INSTALLED I&k ( 1 UNKNOWN <br /> -� <br /> D. CONTAINER CAPACITY: aSQ GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 1 1 02 PRODUCT <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> 1 1 01 UNLEADED 1 1 02 REGULAR ( 1 03,PREMIUM 1 1 04 DIESEL (56 05 WASTE OIL ( 106 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: � ( 1 GAUGE 00 INCHES ( I CM 1 1 UNKNOWN <br /> B. ( I 01 VAULTED (LOCATED IN AN UNDERGROUtRI VAULT) f.,A 02 NON-VAULTED 1 103 UNKNOWN <br /> iC. 1 1 01 DOUBLE WILLED 0(1 02 SINGLE WALLED 1 ) 03 LINED <br /> I0. 1� 01 CARBON STEEL 1 1 02 STAINLESS STEEL 1 ) 03 FI6ERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 1 06 ALUMINUM l 1 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 30 NON-METALLIC <br /> 1 ) 12 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> NGC 04-Oi2185 <br />