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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1)tl O1 NEW PERMIT l 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( 1 09 DELETE FROM <br /> FI LEd NO FEE) <br /> 4 1 02 CONDITIONAL PERMIT _( ) 06 AMENDED PERMIT ( ) OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER - <br /> NAMEl00 PORA TION.INDIVID L OR PUBLIC AO CYI PUBLIC AGENCY ONLY <br /> — � t ,��L� ( 1 01 FED ( 1 02 STATE ( 1 03 LOCAL <br /> /�( P <br /> STREET AD^RESS CITY STATE ZIP <br /> cher <br /> II FACILITY <br /> FACIL Tr NAME DEALER/F PEMEN/SUPERVISOR <br /> l <br /> STREET ADD'ESS (_ NEAREST CROSS STREET <br /> CITY / COVN Y ZIPp.� <br /> MAIL ING ACOPE S CITY STATE ZIP <br /> i - c Qsa <br /> PHONE w,ARE, coo-- _-- TOf BUSINESS <br /> SR) 01 GASOLINE STATION ) 02 OTHER <br /> �. yti . KC�cixO[2l/K-1�4� <br /> NUMBER Cl CONTAINERS RVR At APEAS ONLY TOWNSHIP PANDE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME)LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMEILAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION _ <br /> Rod <br /> A. (jo1 01 TANK ' ( 1 02 OTHER — CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE)! YEAR MFG: " C. YEAR INSTALLED 1 1 UNKNOWN <br /> D. CONTAINER CAPACITY: (000 GALLONS ( 1 UNKNOWN. DDOES THE CONTAINER STORE: ( 1 01 WASTE C)Lf 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (fle) 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 01 UNLEADED l 02 REGULAR 1 1 03 PREMIUM ( l 04 DIESEL l 1 05 WASTE OIL [ 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICYNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE ( 1 INCHES 1 1 CM l ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNOERGROL040 VAULT) (\O 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. t)6 O1 DOUBLE W4LLE0 1 1 02 SINGLE WALLED l 1 03 LINED _ <br /> 0. ( 1 01 CARBON STEEL l 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE l l 05 CONCRETE <br /> ( 1 06 ALUMINUM ( 1 07 STEEL CLAD 1OB l BRONZE 1 ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN (`fi 13 OTHER: ���� limb L-A-12go L rJTIs� <br /> ------_— --- PAGE 1 <br /> HSC04-070185 <br />