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4n.,,d, r:�14— -r6 1(f q�-4, <br /> 0 <br /> STATE IO NUMBER <br /> s APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f 1 1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETt FROM FILE IND FEET <br /> 1 02 C0110ITIONAL PERMIT ( 1 06 AMENDED PERMIT f 1 08 MINOR CHANGE (NO SURCHARGE) <br /> 1 OWNER <br /> NAME ICOP POP ATION,INDIVIDUAL OR FUOLIC AGENCY) PUBLIC AGENCY ONLY <br /> _S/O�/ ya7l'/ 7 _ f } 01 FED { 1 02 STATE { 1 03 LOCAL <br /> l STREET ADORE <br /> /' ^ `j CITY �J �J� ��,/�� <br /> �iTC�:l�f� �'�N / STA t P 7-3 <br /> II FACILITY <br /> FACILITY NAr,E DEALER/FOPEMEN/SUPERVISOP i <br /> �-, ie -- <br /> STFEET AOC=ESS NEAPEST CROSS STPEET <br /> CITY `� - - - ..- <br /> COUNTY 47A/ <br /> ZIPNU Q <br /> MAILING CITY <br /> STAT-* ZIP 91, <br /> PHONE WIACEA CODE TYPE CF 6USiNESS �-� <br /> ( ) 01 GASOLINE STATION 02 OTHER <br /> NUYBEP CF CONTAICS PUPAL AREAS ONLY TOW`iSPiIP . PANGS SECTION <br /> s?l ____— l <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEfLAST NAME FIPST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> tcr/��s M .�.� � - ��°� r'`�=+���/ - j✓ .�-✓ /� � -moi'`/-r�z�.�.5`/ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />�f A. !C' 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLEQ_�. { 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: /�G GALLONS ( } IMKNOW}i E. ODES THE CONTAINER STORE: ( 1 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES t ) 02 NO IF YES CHECK APFROPRIATE BOX(ESI: <br /> ( 1 01 UNLEADED l 1 02 REGULAR { ) 03 PREMIUM (K) 04 DIESEL i 1 05 WASTE OIL 1 ) 06 OTHER <br /> —_ _--------------•�— --- --�_--- ------ter — �— --- — -- <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PP.IMART CONTAINMENT' f ) GAUGE ( ) INCHES { I CM ( I UNKNOWN <br /> B. f 1 01 VAULTED I LOCATED IN AN UNOERGROUlfO VAULT) ! ) .02 NON—VAULTED d 1 03 UNKNOWN <br /> IC. f— 1 01 DOUBLE WILLED,.CX!"f52 SINGLE WALLED f 1 03—LINED <br /> D. 0< ARBON STEEL f 1 02 STAINLESS STEEL i 1 03 FI6ER'GLASS ( 1 04 POLYVINYL CHLORIDE { 1 05 CONCRETE <br /> ( 1 06 ALUMINUM [ } 07 STEEL CLAD f M 08 BR911=E I ) 09 COMPOSITE ( 1 10 NON—METALLIC <br /> { 1 12 L114KNOW11 f 1 13 OTHER: <br /> H5C04-070185 ------__�__�_�-. ------- ---_-- --�-- PAGE 1 <br />