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I <br /> STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNdERGROUNdTSTORAGE TANK - <br /> - — - -- -= ` <br /> -- - - ----- ---- -- -- - ll <br /> -•-- ------ � i ��' 1 ! 09 DELETE FROM FILE tN0 FEE <br /> 1(A 01 NEW PERMIT l ) 05 RENEWED PERMIT <br /> r 1 02 CONDITIONAL PLRMIT { 1 06 AMENDED PERMIT [ -1 08 MINOR CHANGE (NO SURCHARGE) <br />"i OWNER _ <br /> PUBLIC AGENCY ONLY <br /> NAME(COP POPATION.INOIVIDUAL OR FUBLIC AGENCY) t ! 01 FED ( 102 STATE [ 1 03 LOCAL <br /> h _.►n _5__.....- <br /> -`� CITY STATE ZIP <br /> STREET ACnRE55 �_.. S� ^- <br /> II FACILITY - -- -- <br /> DEALER/FGPEMEN/SUPEPVISOP I <br /> FACILITY NAME //� L q <br /> NEAREST CROSS STREET <br /> STREET ACC°ESS �f <br /> — _ <br /> COUNTY i/ ZIP Gj / <br /> CITY c-�///�` '_/ -�- -- / Z�(/ <br /> -----"---..�._.-/_„/--------�"'—' �_�.� � STATE ZIP <br /> MAILING ADDRESS —_--_CITY <br /> .-.-.. ..�-_-.---------------�- -_ <br /> --t- <br /> PPONS W•ACEA CODE T1PE CF BUSINESS <br /> 01 GASOLINE-STATION-1 I 02 OTHER - -`- --��_ <br /> r �- vUP►L APE4S ONLY TOWNSHIP - RANGE SECTION <br /> NUt'OEP CF CONTAINEVS <br /> III 24 HOUR EMERGENCY CONTACT PERSON-- -- - _ — <br /> DAYS' NAr'E�LAST NAME FIPSTI AND PHONE W/APER CODE <br /> F.J.O.LTS� <br /> AMEILAST "A-E FIRST, AND-PHONE W/AREA COOS—J <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. M01 TAPtK ( -1 02 OTHER' CONTAINER NUMBER <br /> B. MA14UFACTUPER (IF APPROPRIATE): <br /> -- <br /> YEAR MFG: C. YEAR INSTALLED — 1 JEBILO <br /> 0. CONTAINER CAPACITY: 10 Q'� GALLOI(S ( ! UNKNOWN E. DOES THE CONTAINER STORE--1 1 01 WASTE [_I 02 PRODUF. DOES THE CONTAINER STORE F10TOR VEHICLE FUEL OR WASTE OIL ? [ 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE <br /> 1 1 01 UNLEADED ( 102 REGULAR ( 1 03 PREMIUM (/-,L 04 DIESEL l 1 05 WASTE OIL t 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ! GAUGE I ! INCHES t ! CM -[ I UNKNOWN <br /> B. I 1 01 VAULTED (LOCATED IN All UNDERGROUND VAULT) 1- 1 02 NON-VAULTED 1 .1 03 UNKNOWN <br /> C. ( ! O1 DOUBLE WALLED �I 02 SINGLE WALLED 1 ) 03 LINED <br /> D. P) 01 CARBON STEEL ( 1 02 STAINLESS STEEL [ ) 03 F15ERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) DS CONCRETE <br /> ( 1 06 ALUMINUM 1 1 07 STEEL CLAD ( ) 06 BRONZE 1109 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN l 1 13 OTHER <br /> ------�------- --- _ PAGE I <br /> }{��0y-O'r0185 <br /> ` I <br />