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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT ( 1 05 RENEWED PERMIT t ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> t ) 02 CONDITIONAL PERMIT 1 l 06 AMENDED PERMIT t ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Q LJa.K STOP VU�N2VkF-- S t ) 01 FED ( 1 02 STATE t ) 03 LOCAL <br /> STREET ACORESSSTATE ZIP <br /> CITY <br /> 5eEm od r <br /> II FACILITY <br /> FACILITY NAME <br /> KA^UE' / � -Roo/F 004*rrt-U ERVZSOR D16r. <br /> STREET ACOtESS NEAREST CROSS STREET <br /> 20 67 CJEsr Lo -ewe z) C g u,(?-C <br /> CITY COUNTY ZIP <br /> LoD� SA'eLJ GAJ 2-`4o <br /> MAILING ADOPESS CITY STATE ZIP <br /> P, 0, 60)4, 5745— 2E OIUT- e,+ 9`I,5-3 <br /> PHONE W%ACEA CODE TYPE CF BUSINESS CoA)vsLf 2Wr-,F N.9,e,*,Er <br /> �50� ( ) 01 GASOLINE STATION 00 02 OTHER �/TH G,456,4 ,-- <br /> NUMBER CF COONTAINEFS RURAL AREAS ONLY To <br /> RANGE TsECTION <br /> -3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAMElIAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE WiAREA CODE <br /> (.,-Ie �t � Q/6 - 36 -83 So <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. t i O1 TANK t D 02 OTHER: CONTAINER NUMBER <br /> B.-MANUFACTURER (IF APPROPRIATE): x E regE S YEAR MFG:/!��% C. YEAR INSTALLED UNKNOWN <br /> 0. CONTAINER CAPACITY: ��� GALLONS ( l UNKNOWN E. OqS THE CONTAINER STORE: ( 1 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X1 01 YES ( D 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 0<1 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL t ) 05 WASTE OIL ( D 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 3�� ( D GAUGE t D INCHES ( ) CM t 1 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IPJ AN UNDERGROUND VAULT) 0`1 02 NON-VAULTEO t ) 03 UNKNOWN <br /> �C• �) 01 DOUBLE WALLED t ) 02 SINGLE WALLED t 1 03 LINED <br /> D. ( ) 01 CARBON STEEL t D 02 STAINLESS STEEL ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) O-5.CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD t D 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON=METALLIC <br /> i ( D 12 UNKNOWN ( D 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />