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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> L�(J O1 NEN PERMIT l ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> )AME(COPPO TION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> l ) <br /> 01 FED 1 ) 02 STATE l ) 03 LOCAL <br /> :TWEET ACORES S. CITY STATE IIP C0 <br /> / 70 o C/� <br /> I FACILITY <br /> •ACITY NAME \ DEALER/FQREMEN'SUPERVISOR <br /> G (/K <br /> iTRlCT A00=fSi NEAR ST CROSS STREET <br /> 70 L O fc <br /> C UN T IIP <br /> MAILIC/N/G ADOPESS CITY STAT IIP <br /> c-. <br /> PHONE W%AREA CODE TYPE OF BUSINESS <br /> l 1 01 GASOLINE STATION 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYSNAME(LAST NAME FIRST) AND PH EA CODE "(i7TffsQA <br /> LAST NAME FIRST) AND PN/NE7.WW//AREA CODE <br /> --'— play/gyp 6p• <br /> COMPLETETHE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. & 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (�4 UNKNOWN <br /> 0. CONTAINER CAPACITY: (Z 0OO GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 HASTE 0—02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? {.t) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BO%IES): <br /> ( ) 01 UNLEADED 1 ) 02 REGULAR ( ) 03 PREMIUM (}K) 04 DIEM ( ) 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM 94—t <br /> UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) A.;(L 02 NON—VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED f ) 02 SINGLE WALLED 1 1 03 LINED <br /> D. 1 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL f 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM l ) 07 STEEL CLAD ( 1 08 BRONZE t ) 09 COMPOSITE ( 1 10 NON—METALLIC <br /> (X.1_12 UNKNOWN l ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />