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• STATE ID NUMBER <br />- � APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> k02NEWPERMIT ( 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(, PPORATION.INDIV UAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Ik/Y� gV t V'\OL ( 1 01 FED ( ! 02 STATE ( ) 03 LOCAL <br /> FEET ADDRESS l` CITY STATE IIP <br /> 3 �n m - � Sa s a VVN C� L09 <br /> 6 <br /> II FACILITY <br /> FACI TY NAME DEALS /FOPEMEN/SVP V 7 <br /> a l n o L,J ea K n C� - � a l ri�-- <br /> STPCE AD PCSS NEAREST CROSS STPEET <br /> i �' 1A a a a �n + <br /> OB <br /> CITY COUNTY I Sa`f <br /> Lp <br /> MAILING ADORES CITY e _ SST^p�Tc�.� <br /> PHONE W.' PEA CODE_ ^ TYPE OF BVSINESS <br /> 1lO'j�`l 3 XU ( 1 01 GASOLINE STATION ( ) 02 OTHER <br /> NUY.BE CONTA2NERS RURAL AREAS ONLY TOWNSHIP PANGS SECTION <br /> I <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYNAf:E(lAST NAME FIRST) ANO PRONE W/AREA CODE NI HTS: NAME(LAST AME FIRST) AND PH W/AREA,CODC <br /> v�o-- 03415 66 )Y/S/O JZOQ <br /> -- ) r7avti <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (y) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ��-l _ 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: 1000 .GAJLLONS ( ) UNKNOWN E. DOES�TTHE CONTAINER STORE: ( 1 01 WASTE 7 J 02 PRODUCT <br /> ,F. DOES THE CONTAINS TORE MOTOR VEHICLE FUEL OR WASTE OIL ? y�) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED ( 02 REGULAR l 1 03 PREMIUM l 1 04 DIESEL ( ) 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( 1 CM ( 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (JG NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED -02 SINGLE WALLED ( l 03 LINED <br /> D. l 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL 1 ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE t ) 05 CONCRETE <br /> l ) 06 ALUMINUM ( ) 07 STEEL CLAD l ) 08 BRONZE ( ) 09 COMPOSITE- ( 1 10 NON-METALLIC <br /> 1'2 UNKNOWN ( 1 13 OTHER: <br /> l6PAGE 1 <br /> IHSC04-070185 <br />