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L <br />STATE IO NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />1 1 01 NEW PERMIT ( 1 05 RENEWED PERMIT t 1 07 TANK CLOSED t 1 09 DELETE' FROM FILE (NO FEE) j <br />( ! 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />HAttE(COPPORATION.IN IVIDUAL OR CUB IC AGENCY) <br />STPEET ACTRESS <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />- t 1 01 FED I ) 02 STATE ( 1 03LOCAL <br />CYTY STATE Jz; <br />L w A <br />FACILITY NAME <br />c <br />DEALER/FOPEMEN/SVPERVISOP <br />--- <br />— <br />STREET ACCESS <br />NEAPEST CROSS TPEET <br />CITY <br />_. C ®CA <br />COUNTY <br />ZIP <br />t <br />MAILLNG ADDPESSCITY <br />_ <br />STATE ZIP <br />PHONE W%ACEA COOS JTVP OF BUSINESS <br />- - - - O1 GASOLINE <br />STATION ( ) 02 OTHER <br />NUMBER CF CONTAINEPS <br />PUPAL APEAS ONLY <br />TOWNSHIP <br />PANGE <br />SECTION <br />i 1 i <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />v `A. (XI 01 TANK ( ) 02 OTHER: <br />S. MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG_ <br />CONTAINER NUMBER <br />C. YEAR INSTALLEO ( ) UNKNOWN <br />0_CONTAINER CAPACITY: 40(.70 GALLONS t ) UNKNOWN I E. DOES THE CONTAINER STORE: ( 1 01 WASTE l 02 PRODUCT - -_- <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? t 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br />--( ) 01 LPJLEADEO ( 1 02 REGULAR ( 1_03 PREMIUM t-) 04 DIESEL ( ) 05 WASTE OIL IV 06 OTHER <br />V CONTAINER CONSTRUCTION i <br />A. THICKNESS OF PP.IMARY CONTAINMENT: 1 1 GAUGE (X) INCHES l i CM 1 i UNKNOWN <br />B, ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (V' 02 NON -VAULTED ( 1 03 UNKNOWN <br />IC. ( 1 01 DOUBLE WILLED 1 02 SINGLE WALLED t ) OS LINED <br />0. l ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 F16ERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />( ) 06 ALUMINUM 1 ) 07 STEEL CLAD ( 1 08 8ROtIZE ( 1 09 COMPOSITE f D 10 NON-METALLIC <br />1 ( 1 12 UNKNOWN ( 1 13 OTHER: <br />►I;iC04-00185--------------- ----- PAGE i <br />J <br />