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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> p01 NEW PERMIT ( 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED l 1 09.OELETE FROM FILE (NO FEE <br /> 02 COtIDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (N0 SURCHARGE <br /> I OWNER -- - ----- - ---.. <br /> H<M!-1CORPOR<TZON.INCIV IDUAI OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 4 LO SSO C^ ..�-n/,-.- l 1 al FED 1 1 02 STATE 03 LOCAL <br /> ITP-ET CITY STATE LIP <br /> AC'iPF:S <br /> � S 7/�,r✓ ell ySZaY_ <br /> II FACILITY <br /> FACILITY NAME DCALCR/FOPEMENISUPERVISOR <br /> /�c C_f� L�SSO .� Som/ �!✓ -- A17,4,-- <br /> NEAREST <br /> rAfNEAREST CROS srveET <br /> CITY � LG / covNrr <br /> MAILING 'DOVES;.-7 �-D /�J <br /> at/ �, /� /y,�C CITY �i STAT ZIP 2_05 <br /> PHONE W•♦A<EA CODE / TYPE OF BUSINESS ` <br /> 1 01 GASOLINE STATION (N 02 OTHER <br /> NUYOlP OF CONTAIIE:$ — RURAL AREAS ONLY TOWNSHIP R<NOE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> �DAYS: NArfIIAST NAM[ If►STI ANO PRONE W/ARlA COO[ NIGHTS: NAMCILAST NAME FIRSTI AND PHONE W/AREA COOC <br /> ssa�icGrsk ��4.�f66 9�/�f� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. X1 01 TAfK f 1 02 OTHER__ _ CONTAINER tArtWER ---- <br /> B. MANUFACTURER (IF APPROPRIATEI__— —- _ YEAR MFG: C.YEAR INSTALLED _ ln) UNKNOWN <br /> D. CONTAINER CAPACITY: 'O,UV GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE 1 1 02 PRODUCT <br /> F. DOS THE CONTAIIIER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOKIESI: <br /> (V'1 01 U:ILEADEO 11 02 REGULAR 1 1 03 PREMIUM 1 1 04 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> IA, THICENESS OF PP.IMARY CONTAINMEIIT: 1 1 GAUGE 1 1 INCHES 1 I CM } UNKNOWN <br /> IB. f 1 Ol VAULTED (LOCATED IN AN Ut1OERGROUND VAULT I- 1/x,1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. 1 1 Ol DOUBLE WILLED 02 SINGLE WALLED 1 1 03 LINED <br /> I0. 1 101 CARSON STEEL 1 1 02 STAINLESS STEEL 1 1 03 F16ERGLASS 1 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( 106 ALUMINUM 1 1 07 STEEL CLAD I 1 OB BRO112E f 1 09 COMPOSITE 1 1 10 NOt1-METALLIC <br /> f 1� 17iCNKNOWN l 1 13 OTHER: <br /> LPA _.__ __ _ _.. -_ .. ___ ___. _ — _ <br /> PAGE i <br /> u 3!'04-0,^185 . <br />