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STATE 10 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f� NEW PERMIT t 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED t ) 09 OELETt FROM FILE (NO FEE) <br /> T 1 02 CONOITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE IND SURCHARGE) <br /> I OWNER <br /> L <br /> LY <br /> NAME(COPnORATION.INCIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY bNO2OL FfD I 1 42 STATE f I LOCAL <br /> Z4 e <br /> 12 f <br /> SroiLT ACTRESS CITY � <br /> STATE <br /> ZIP Z <br /> II FACILITY <br /> FACILITY NAME Lb EALEA/FOP EMEN/SUP EPVI SOP <br /> 14 1-4 <br /> STFEET NEAREST C4 S/ T <br /> CITY �f / COUNTY J/��j ,�/ ZIP <br /> zk- <br /> STATE zIRL] <br /> MAILING A OPESS 'CIrY <br /> PHONE Wo-ATEA CODE TYPE OF BUSINESS <br /> + � t 1 01 GASOLINE STATION (X02 OTHER <br /> NUYBE! CF CONTAIyERS PUPAL AREAS ONLY TOWNSHIR PANGS SECTIDN <br /> 1II 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAMErLAST NAME FIPST) AND PHONE W/APER CODE NIGHTS: NAM (LAST NAME fIR2T1 AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION ---- - <br /> 1 OI TAtOC [ I 42 OTHER. CONTAINER NUMBER �f'�j�� <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLEdL 1 UNKNOWN - <br /> D. COIZTATt2ER CAPACITY: GALLONS 1 1 UNKNQWN �OOE�STHECONTAINER STORE: 1 I OL WASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAINERSTO�R VEHICLE FUEL OR WASTE OIL ? t 1 01 YES l i 02 NO IF YES CHECK APPROPRIATE BOM(ESI: <br /> 1 1 01 U.'ILEADCO [ 1 02 REGULAR S F 03 PREMIUM X) 04 DIESEL 1 ) 05 HASTE OIL _i ) 06 OTHER- �- <br /> V CONTAINER CONSTRUCTION —_�_—.—._---.----- ---.. <br /> A. THICKNE5S OF PRIMARY CONTAINM€NT: [ 1 GAUGE 1 1 INCHES I 1 CM 1 I UNKNOWN <br /> B. { 1 01 VAULTED (LOCATED IH AN UIOERGROUtIO VAULT) -1T 1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. ! 1 01 DOUBLE WkLLED ! SINGLE WALLED [` 1-03-L1[IED - - - -T- ^---� --T -_..------ - <br /> - - - <br /> D. /j 8f CARBON STEEL f 1 02 STAINLESS STEEL [ 1 03 FIBERGLASS f } 04 POLYVINYL CHLORIDE ( 105 CONCRETE <br /> 1 106 ALUMINUM 1 ) 07 STEEL CLAD t 1 06 BRONZE I ) 09 COMPOSITE i 1 10 NON-METALLIC <br /> ( 1 12 UIiKNOW11 t 1 13 OTHER: <br /> ---- -- ------ --- ---------_ --- ---------- ------- PAGE 1 <br /> H5C04-070185 <br />