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Tk.v 4-an K <br /> STATE 10 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f O1 NEW PERMIT f 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INOIVIDUAL OR PUBLIC ApNCYEY PUBLIC AGENCY ONLY <br /> (V/V/ r ( ) O1 FFD f ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS C y e/ <br /> •� ©, B � ,z hble STATE LIPry3/� <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPE VIS q <br /> Lf., C9(l. `�Ac(_ I @�V I/ 0.l _ <br /> STREET ADDRESS NEAREST CROSS STREET <br /> T <br /> CITY COV Y IIP <br /> MAILING ADDRESS - CITY ,.fA� <br /> S L Vo VL I ST Z� ,Gf <br /> APEA CODE TYPE OFEASINESS <br /> 6ASOlINE STATION ( 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODENIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 4-01 TANK ( .1 02 OTHER: CONTAINER NUMBER `r <br /> B. MANUFACTURER (IF APPROPRIATE): C.wOVS �� 1ti1G YEAR MFG:k)pw C. YEAR INSTALLED WrUNKNOWN <br /> 0. CONTAINER CAPACITY: SSo GALLONS f ) UNKNOWN E. DOES 7HE'CONTAINER STORE: (vT O1 WASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f ) <br /> 01 UNLEADED ( 1 02 REGULAR 1 ) 03 PREMIUM ( ) 04 DIESEL (LJ-05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE f ) INCHES ( ) CM ((-YOFKNOWN <br /> B. ( ) 01 VAULTED ILOCATED IN AN UNDERGROUND VAULT) l 0-�2 NON-VAULTED (. ) 03 UNKNOWN <br /> C. (LIK'01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> 0. 1 ) 01 CARBON STEEL f ) 02 STAINLESS-STEEL ( w-03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> t 1 06 ALUMINUM ( ) 07 STEEL CLAD l ) 08 BRONZE ( ) 09 COMPOSITE f l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSCO4-070185 PAGE 1 <br />