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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> I 01 NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORP P AT ION,INDIVIOUA� OR PUBLIC AGENCY) <br /> •� PUBLIC AGENCY ONLY <br /> ( O1 FED 1 1 02 STATE ( 1 03 LOCAL <br /> lTRElT ADOglSS <br /> 44 CITY 3T TE IIP <br /> � 7 <br /> II FACILITY <br /> PACIL <br /> ILNAME Ol4L /FOREMEN/SUPE RVIS R <br /> NEAREST CROSS STRICT <br /> ICITY <br /> 57-ke•L/y may-b �,,^) COU / <br /> _ -4rov, 7S io�S <br /> ;i!#H0NE <br /> MAIlINO ADDRlSS CITY STA !_ 2IP <br /> ewlb <br /> iAPIA CODE TYPE OF BUSINESS <br /> T_ O1 GASOLINE STATION ( 02 OTHER Zilfj `P CONTALNCRS PUPAL AREAS ONLY : TOWNSHIP RANGE SlOTION r <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> F_ <br /> DAYS: NAVEL UST NAME FIRST) AND PHONE W%�=A CODE NIGHT�AMC(LAST NAME FIRST) AND PHONE W/ARCA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> (IV DESCRIPTION <br /> I <br /> IA ( 01 TANK f 1 02 OTHER: CONTAINER NUMBER 63 R TR <br /> B. MANUFACTURER IIF APPROPRIATE): YEAR MFG+ C. YEAR INSTALL ( ) UNKNOWN <br /> II - r <br /> D. CONTAINER CAPACITY: GALLONS 1 ) UNKNOWN I E. DOES THE CONTAINER STORE: ( 1 01 WASTE (A 02 PRODUCT <br /> F_ D015 THE CONTAINER STORE MOTOR VEHICLE FUEL OR WAS OIL ? ( ) 01 TES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> 1 ) 0 <br /> 1 UNLEADED ( ) 02 REGULAR t 1 03 PREMIUM <br /> l 04 DIESEL ( ) OS WASTE OIL 1 ) 06 OTHER <br /> Y CONTAINER CONSTRUCTION <br /> i <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( 1 CM 1X1 UNKN01* <br /> 18. I 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) IxM 02 NON-VAULTED ( 1 03 LR0(HOWN <br /> i <br /> C. t 1 01 DOUBLE WALLED IX 02 SINGLE WALLED l 1 03 LINED <br /> 7. 01 CARBON STEEL l •1102 STAINLESS STEEL l 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE 1 ) 05 CONCRETE <br /> t ) 06 ALUMINUM 1 ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> -5:04-070185 --_— — --_--- —� � PAGE 1 <br /> ol <br /> Not <br /> M <br />