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2 • STATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 0 <br /> 1 NEW PERMIT l 1 05 RENEWED PERMIT- ( ) 07 TANK CLOSED _ - 1 1 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT 1 1 OB MINOR CHANGE IND SURCHARGE) <br /> I_ OWNER <br /> NAM'-)COP pTf OA) `V IDUALt+T �PUBLICAGENCY)� W �S� PUBLIC AGENCY ONLY -LO <br /> IVl W �� 1 C �- ( 1 Ol FED ( 1 02 STATE ( 1 03 LOCAL <br /> STREET A"RESS <br /> -�^ O �` CITY STATE LIP <br /> (i l t ✓LL t+rul TE C �} <br /> II FACILITY <br /> FAC I}�TY NAME . DEALER/FOPEMENISUPERVISOR <br /> 11K A l_YJ <br /> STREET ACCESS NEARE CROSS STREET <br /> —�1-D W OS £ wlr TF AA lot t o S <br /> CITY COON Y ZIP /1 <br /> tc A LLt r21 r2 S tl r n <br /> MAILING ADDRESS CITY STATE ZIP <br /> PHOPHN. W/A23CODE <br /> � • TYP F BUSINESS <br /> � O0 <br /> 1 01 GASOLINE STATION f ) 02 OTHER N4 I N•\ v_ <br /> NVMpER OF CONTAINERS -- PAL AREAS ONLY TOWNSHSP RANGE / SECTION <br /> VR <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME(L4ST NAME FIPSTI AND PHONE W/AREA CODE NIGHTS: NAME(IAST NAME FIRST) AND PHONE W/AREA CODE <br /> �? ^E `L � hfit�o51423 - boa3 S A <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTIONr& E_J; '�j 1qfCIFE C° 0 Q — £ST "Tr1t1K.t Ag Sg 1 <br /> A. ( 1 01 TANK ( 102 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS 1 ) UNKNOWN E. DOES THE CONTAINER STORE: 1 ) 01 WASTE ( 1 02 PRODUCT <br /> F. (TOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES 1 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f 1 01 U4LEADEO ( 1 02 REGULAR l 1 03 PREMIUM 1 l 04 DIESEL l 105 WASTE OIL t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES 1 1 CM t 1 UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 102 NON-VAULTED ( 1 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( 1 03 LINED <br /> D. f 1 01 CARBON STEEL 1 ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> f ) 06 ALUMINUM 1 ) 07 STEEL CLAD 1 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN O 13 OTHER: <br /> HSC64-Oi9185 PAGE 1 <br />