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4. <br /> Y � <br /> STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STp(tA6E�jANl4 sr ,., 1?1.,„ <br /> 1x1 <br /> 01 NEM PERMIT Of RU*WEO;PENMIT 4 .1 27 TANK CLOSED ,1, 1.#tj OEIETC?TROM f�LF._IMD FEET <br /> E 1 02 CONDITIONAL PERMIT 1 1 O6 AMENDEO PERMIT 1 1 00 MINOR CHANGENO Oj <br /> ( JRg1AR1{E) <br /> I OWNER <br /> NAME(CON CORATION.IN10IVII�0""U�&,t� pI0 f {IC AOeNOn PUBLIC AGENCY ONLY <br /> Ali Iill,oL! Y4 �✓�^1. A 1 01 FEB 4 1 02 STATE (. 1 01 LOCAL <br /> . sntn Ao64I58 <br /> t f OI _ LTA t <br /> II FACILITY <br /> FACILTV N C OEALCN/ PcMCN'SvPt11VISOR <br /> n <br /> STRICT AOB•ess HIARCST COCA STRICT <br /> CITY � COSTY <br /> NAILtMo 'Aoor[ssr CITY141 <br /> ' rNON[,Nu�AcI& CODE TYPC Of SU*I"tss - - <br /> '(G[•j-6�3 1 1 01 GASOLINE STATION 0,4 02 OTHER W <br /> /AILRU C' OMTAINIrt RVRAL AREAS ONLY iONNIXi/ •ANO! SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEKLAST N ! / 'fTl"ANO INONC N/ARCA COOC NIONTfi NAMCI LAST M F ftTl AND INONf N/ARlACOOf <br /> L✓o-013IV <br /> 1 S+cveS'k� � i) <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> SS A. ( ) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE):. YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> 0. CONTAINER CAPACITY: I GOD GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 Ol WASTE 1X1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL I 1 1 O1 YES 1 1 02 NO IF YES CHECK APPROPRIATE BO%(ESI: <br /> 1X1 01 UNLEADED ( 1 02 REGULAR t 1 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE ( I INCHES 1 1_CM 0<1 UNKNOWN <br /> IB. I 1 01 VAULTED (LOCATED IN AN UIOERGROUO VAULT) 1 ) 02 NON-VAULTED IX) 03 UNKNOWN _ <br /> C ( 1 01 DOUBLE WALLEO 1 1 02 SIIK:LE WALLED 1 1 03 LINED <br /> 0. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL / 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD ( 1 06 BRONZE 1 1 09 COMPOSITE l 1 10 NON-METALLIC <br /> I f6 12 LINKNOWN ( 1 13 OTHER: <br /> H5CO4-0:0185 ` PAGE 1 <br />