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STATE <br /> APPLICATIONFOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK / <br /> .R.1 _ <br /> OI NEW PERMIT l ) 05 RENEWED PERMIT <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 06 MINORCLOSED f 1 09 DELETE FROM FILE (NO FEE) <br /> CHANGE (NO suRCHARGEI <br /> I OWNER - <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AOENCYI <br /> PUBLIC AGENCY ONLY <br /> 1 1 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br /> STpElT ACORCS S_ t <br /> CITV�� STAT <br /> --- � Ig�ZoG <br /> II FACILITY <br /> FACILITY NAME /� T� <br /> /rF ' ^�A--A A �/_+ L- C,� //V DEALER/FOR lItl N�SVPERVISOR <br /> STREET ADD=ess / `-v ) 'v{ l.r I I K ?D/(/f L INSOZt <br /> 7 �'7 2 � {I I �Vy O� NEAREST CROSS STREET <br /> CITY w 4 1. ' �/ <br /> COUNTY IIP <br /> S frza 6' <br /> MAILINO AO-�D/fP�l SS�7 [� /L/ CITY �/v 7/� <br /> I--.Y- G } / �I V �I � STATE ZIF <br /> �/`/vc <br /> PHONE W-AEEA CODE TYPE OF BUSINESS 1 <br /> 1 1 01 GASOLINE STATION 1 02 OTHER <br /> NUMBER CR CONTAIQIC Rs PUPAL AREAS ONLY : TOWNSHIP <br /> (/ RANO! SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NTAY�,EfLAST NAME ) AND iC NE W / O� <br /> eA CODE <br /> NIONTS: NAMEIlAST NAME FIRST) AND PHONE W/AREA CODE <br /> _99 /a� _ _ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 ) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): TEAR MFG: C. YEAR INSTALLED Xf LWHOWH <br /> D. CONTAINER CAPACITY: /010(Zl GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 HASTE ( 1 02 PRODUCT <br /> F. D THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 TES 1 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> 1 <br /> 0 <br /> 1 UNLEADED l ) 02 REGULAR l 1 03 PREMIUM ( ) 04 DIESEL 1 105 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM ( UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l ) 02 NON-VAULTED P<) 03 UNKNOWN <br /> Ir C. ( ) 01 DOUBLE WALLED ) 02 SINGLE WALLED 1 1 03 LINED <br /> D. 01 CARSON STEEL ( ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> IL1 ) 06 ALUMINUM l ) 07 STEEL CLAD ( ) OB BRONZE 1 1 09 COMPOSITE ( ! 10 NON-METALLIC <br /> t 1 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> La/ �/ <br />