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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (At 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) i <br /> t ( 1 02 CONOITIONAL PERMIT ( 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I--OWNER-- —----- -- -- - ----- ----- --- - — - -- - <br /> NArE(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> C U --- - - - ( 1 01 FED 1 ) 02 STATE t ) 03 LOCAL <br /> STREET ACTRESS I I <br /> TC <br /> IyY FST�CA <br /> TEZIP <br /> �tif�U3 <br /> II FACILITY <br /> ''-ACILITr NAME DEALER/FOPEMEN/SUPERVISO <br /> Imo ��- � � ~OIn <br /> STREET ACC°ESS NEAREST CR SS STPEE <br /> (,� <br /> CITY COUNTY ZIP <br /> _J lJ�',_ <br /> MAILING ADDPESS CITY U STATE ZIP <br /> ___l <br /> PHONE W•ArEA CODE TYPE CF BUSINESS <br /> �Q <br /> 01 GASOLINE STATION l 1 02 OTHER -- <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> (DAYS: NAME(LASTNAME FIPST) AND PHONE W/APER CODE NIGHTS. NAME(IAST NAME FIRST) AND PHONE W/APEA CODE <br /> C O W Ci`>o v►ay►c e - - (�0 - <br /> f <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TANK ( ! 02 OTHER: CONTAINER NUMBER a <br /> B. MANUFACTURER (IF APPROPRIATE)% OWNY15 Cnl„yl —--- YEAR MFG: C. YEAR INSTALLED/I��� ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: ��1��[� GALLONS l 1 UNKNOWN E. ODES THE CONTAINER STORE: ( 1 01 WASTE 11,02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? >4 01 YES ( 1-02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> ( 1 01 UNILEADED- D4 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( 1 CM 10>4 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (>'Q 02 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. vjL1 01 DOUBLE WALLED ( 1 02 SINGLE WALLED 1 1 03 LINfO <br /> D. 1 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 1 06 ALUMINUM l 1 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER: <br /> t5C04-07n185 PAGE 1 <br />