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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 NK 01 NEW PERMIT 1 1 OS.REMEMED PERMIT 1 1.07 TACL05ED 1' 1 09 DELETE FROM FILE IND FEET <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 06 MINOR CHAHGE'(NO SURCHARDE►- <br /> I OWNER <br /> NAMI(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> l 1 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> STPLET AADn PISSIS.// r CITYY ST/ArT! IIP <br /> W_ l..Yc tiz�attou[ J ACKTD LL L._o <br /> II FACILITY <br /> FACILITY NAM! n4 7`5 <br /> DEALER/FOPEME NISVPEPVISOR <br /> IYII / _ <br /> ST121T ADD-ESS NEAREST CROSS STPEET <br /> sa.Q�._ Z�nrouT <br /> CITY COUNTY �. IIP <br /> _ qAM �54AJ ( I'SZOS, <br /> MAILING ADDPESS CITY STATE IIP <br /> 4m __12F, 67VC�_-T70 _ Cao <br /> PHONE WACEA CODE TYPE OF BUSINESS <br /> E 1 01 GASOLINE STATION l>602 OTHER P(,(BTP (Z F fW tt 1 5144Fjr <br /> Murat* ,C ONTASNI SS PVP At APEAS ONLY : TONNSNIF PANGS SECTION-- <br /> III 24 HOUR EMERGENCY CONTACT PERSON _ <br /> DAYS: NAMEILAST NAME FIPSTI AND PHONE W/APEA COO! NIGHTS: NAMEILAST NAME FIRSTI AND PHONE WIAPEA COOS <br /> L YQsI _ -m B'817 � d,u� `iltC/�IILrS s ssn <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. Tt<l 01 TAt?K ( 1 02 OTHER CONTAINER NUMBER <br /> S. MANUFACTURER LIF APPROPRIATE): YEAR MFG: _ C. YEAR INSTALLED/Tr7 1_1 UNKNOWN <br /> 0. CONTAINER CAPACITY:_ 515_ GALLONS 1 ) UNKNOWN E. ODES THE CONTAINER STORE: 1 1`OI WASTE (5d 02 PRODUCT <br /> F. DOES THE COtITAI1IER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES I 1 02 NO IF YES CHECK APPROPRIATE BO%(ESI: <br /> 1 1 01 UNLEADED 1V1 02 REGULAR l 1 03 PREMIUM 1 1 04 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TH ICY.NESS OF PRIMARY CONTAINMENT: 1 1 GAUGE f 1 ItICHES 1 1 CM 1 UNKNOWN <br /> 8. 1 1 '01 VAULTED (LOCATED IN At/ UNDERGROUND VAULT) 1 1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE MILLED ')' 02 SINGLE WALLED ( 1 03 LINED _ <br /> 0. 1� O1 CARBON STEEL ( 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 08 BROIILE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> l 1 12 L44KHMI ( 1 13 OTHER: <br /> HSC04-07n185 _._--- PAGE 1 <br />