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NAMPO *Wf STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 27'K41 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TAM( CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> 102 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPO�OI:;.7Z /VALIOR 1 � 1C ZNCY) PUBLIC AGENCY ONLY <br /> 1►VI p�� ! LSO %Y_ 1 1 01 FED 1 1 02 STATE ( ) 03 LOCAL <br /> STREET AC'f4EiCITY STATE_ <br /> II FACILITY <br /> FACILITY NAME <br /> A LVA,N G DEALER/POPC MlN/SVPERVISOR <br /> STREET ACCESS NEAREST CROSS STREET - -.- <br /> J.00�4 1b2iye, <br /> CITY /l�O' + / � COUNTY g ,, Ip q <br /> MAILING ADDIEss �J 'va, CITY s-;w — STATE ZIP��� <br /> PHONE W.Area CODE TYPE CR DUSINE SS <br /> �� — 17 � � 7Q ( 1 O1 GASOLINE STATION 02 OTHER <br /> NUMDEp C• CONTAINED% PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NA T eNAME FIRST) AND PHONE^=//AREA CODE ��O NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/ARCA CODE <br /> 2nd-9�/-27&C <br /> 93/—/so / <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINEfh31_2v <br /> 8� im" <br /> IV DESCRIPTION 77 <br /> A. 0< 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE Y _ _ YEAR MFG: C. YEAR INSTALLED k1 UNKNOWN <br /> 0. CONTAINER CAPACITY: IgpC)o GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE l 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE.OIL ? ( 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES), <br /> 1 1 <br /> 01 UNLEADED 1 1 02 REGULAR ( 1 03 PREMIUM _(w 04 DIESEL 1 1 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TM ICY.NESS OF PRIMARY CONTAINMENT ( 1 GAUGE f 1 INCHES f 1 CM IBJo UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED 1 1 03 UNKNOWN <br /> �.1 DOUBLE WALLED (>& SINGLE WALLED 1 1 03 LINED <br /> 0. 1 1 01 CARBON STEEL l 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD [ 1 08 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (xl 12 UNKNOWN ( l 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />