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a STATE IO NUMBER <br /> APPLICATION FOR . PERMIT TO OPERATE UNDERGROUND STORAGE•µ-:TANK <br /> 1 Ol ! f PERt1IT - t1 05 RENEtO`!'ERMIT ( 107 TANK CL03E0 t, i 89 QELETC FROM FILE tNO. FEE i <br /> I Ot CONDITIONAL PERMIT t 1 06 A"ENDEO PERMIT ( 1 OQ MINOR CHANGE (N10 SURCHARGE) <br /> I OWNER <br /> NAME CORPORATION. NOIVtOUAL 01 PUOL C AGCNCYI PUBLIC AGENCY ONLY <br /> P t ! <br /> 01 FED t 1 02 STATE t 1 03,LOCAL <br /> SirwttT AO�RESf 5' CIT _ STA Z> <br /> , <br /> II FACILITY <br /> FA LITY NAME OEAR/FOREMEN DERV SOS <br /> ST T 02Ess NEAPS T CROSS STREET„ <br /> CITY - COUN ZIP "--P <br /> MAILING ADOPESS CITY ' ST ZIP <br /> PHONE W%AeE® COOS P OF WSINEiS <br /> �- ►o- / 01 GASOLINE STATION (` 1 02 OTHER <br /> NLw.8ER cP CONTAINERS RURAL AREAS ONLY SHIP PAHOE SECTION, <br /> TOWN <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: <br /> !f LAST N C PST/ AND PHONE W/AREA COOS NI TSS NAME(LAST NAM SRST1 AND. PHONE W/AREA COOS <br /> Lc <br /> f 3� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> g A. D 01 TANK t 1 02 OTHER= CONTAINER NUMBER <br /> - B. MANUFACTURER IIF APPROPRIATE 1:_ -_ YEAR MFG C. YEAR INSTALLED_, Lq <br /> ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: � 0t GALLONS t 1 UNKNOWN E. DOES THE CONTAINER STORE: t 1 01 WASTE ( 102 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> t 1 01 UtILEAOEO ( 1 02 REGULAR t 1 03 PREMIUM 1 04 DIESEL t 1 OS WASTE OIL ( 1 06 OTHER _ _- <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t 1 GAUGE ( 1 INCHES t 1 CM l- 1 UNKNOWN <br /> B. t 1 01 VAULTED (LOCATED IN AN UNOERGROUt10 VAULT) 't> <br /> t 02 NON-VAULTED ( 1 03 UNKNOWN <br /> (C. ( 1 01 DOUBLE WALLED ) 02 SINGLE WALLED ( 1 03 LINED <br /> 01 CARBON STEEL ( 1 02 STAINLESS STEEL t 1 03 FIBERGLASS t 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM l ) 07 STEEL CLAD ( 1 08 BROttZE ( ! 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ! ( 1 12 UNKNOWN ( 1 13 OTHER <br /> PAGE 1 <br /> - ti'sL04-0 7 0185 _ <br />