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:ce <br /> � STATE ID NUMBER <br /> APPLICATION 'FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> tl O1 NEW PERMIT l 105 RENEWED PERMIT 1 1 07 TANK CL05EO 1 1 09 DELfTE' FROM FILE (NO FEEL <br /> T 1 Oc COHDITIONAL PERMIT 1 } 06 AMENDED PERMIT ( 1 08 MINOR CHANGE IND SURCHARGE) --— - - <br /> I 0WNER - - - <br /> NAKEiCOARCRATION,INDIVIDUAL. OR PUBLIC AGENCY) PLIOLIC AGENCY ONLY <br /> 1 1 O1 FED 1 1 OZ STATE ( } OS LOCAL <br /> STREET AD'7aESS 6,fllf? fJ/f�/✓� CITY //��''R✓l� STATE <br /> zYP Z ! <br /> II FACILITY - - <br /> FACILITY NAMEDEALER/FOPEMEH/SVRfRVISOR <br /> 2� G (,�Lf7 -- /L @ f <br /> STREET RCD°CSS CF/V^f NEAREST CaCSS STREET <br /> CITY COUNTY A IZIP <br /> MAILING ADDRESS�7 <br /> CITY STATE ZIP <br /> PHONE Wl AVEA CODE TYPE OF 5USIN£SS <br /> ( 1 pl GASOLINE STATION 02 OTHER C)tiff�7 /L <br /> LVI <br /> 6EP CF CONTAINERS RURAL kREA$ ONLY TObI,ySHIP — PANG£ SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEILAST NAME FIPSTI ANO PHONE W/AREA CODE NIGHTS: HAMC(IAST NAME FIRST) AND PHONE W/AR CODE <br /> Jf <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION ----- <br /> A. [A).,Dl TAfK t 1 02 OTHER: CONTAINER NUMBER <br /> -- �� <br /> B. MANUFACTUER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED —�� I-1 UNKNOWN <br /> R <br /> 0. CONTAINER CAPACITY: f/ GALLONS 1 1 UNKNOW}) E. DOES THE CONTAINER STORE: I ) 01 WASTE ( 1 02 PRODUCT — <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 101 YES [ } 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ! 1 01 U,ILEADLD { 1 02 REGULAR 1 1 03 PREMIUM (')(I 04 DIESEL f 1 05 WASTE OIL ( 1 06 OTHER - <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PP.IMARY CONTAINMENT- ( ! GAUGE 1 i INCHES f 1 CM ( ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNI)ERGROUIID VAULT) f 1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. I ) 01 DOUBLE WILLED 02 SINGLE WALLED I 1 03 LINED <br /> D.. iNIp CARBON STEEL ( 1 02 STAINLESS STEEL [ f^ 03 FIrERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 0E ALUMINUM 1 1 07 STEEL CLAD ( 1 08 BROOZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN l 113 OTHER: <br /> - --------- _ - - ----- ----- --- ---�--- ----- --------- -- --- -------- ---�----- -- PAGE 1 <br /> H'V4 .0:0185 <br /> .tea, <br /> r q <br />