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STATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t 1 01 NEW PERMIT I ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEED <br /> t D 02 CONDITIONAL PERMIT t ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER DDD <br /> NAME(COPPORATION.INOIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET AODRESS <br /> jl:TY STATE Fz <br /> ZP <br /> __� <br /> k, <br /> se �P ,eEm o,d r C'�1- 9 k <br /> I FACILITY <br /> FACILITY ",WK� %7oP � P.KE' /�g oEAo R/F� w•s�eavasoRDIST <br /> .. — <br /> STAEET'ADD ESS NEAREST CROSS STREET <br /> 0).-sr ,t!oG ewez) C_404 4' <br /> czav <br /> COUNTY ZIP <br /> MAILING ADOPESS CITY STATE ZIP <br /> 2E oN•r- WS-37 <br /> PHONE W%ACEA CODE TYPE CF BUSINESS �NVEILS/INCE /NAI�KET <br /> 01 GASOLINE STATION UC) 02 OTHER 66 7H (!574soZAlr <br /> NUN.DER CF CONTAINERSPUPAL AREAS ONLY [ TOWNSHIP PANGS SECTION <br /> - ---- <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS' NAME(LAST NAME FIRST) AND PHONE W/APER CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> G O-IFF . Q/6 - 36 V-93 So <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. X) <br /> 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> 8.--'MANUFACTURER LIF APPROPRIATE): X YEAR MFG:/,aC. YEAR INSTALLED �`�! t ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS t D UNKNOWN E. ODES THE CONTAINER STORE: ( 1 01 WASTE (JCB 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHI LE FUEL OR WASTE OIL ? (><) 01 YES t D 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t 1 01 UNLEADED ( ) 02 REGULAR 03 PREMIUM ( ) 04 DIESEL ( D 05 WASTE OIL t D 06 OTHER <br /> n, <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: .36'0 t D GAUGE t ) INCHES ( 1 CM ( ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN Aft UNDERGROUND VAULT) X) 02 NON-VAULTED ( D 03 UNKNOWN <br /> DOUBLE WALLED ( ) 02 SINGLE WALLED ( D 03 LINED <br /> 0. t / 01 CARBON STEEL ( l 02 STAINLESS STEEL 06 03 FIBERGLASS ( / 04 .POLYVINYL CMLORIDE t ) 05 CONCRETE <br /> t ) 06 ALUMINUM l ) 07 STEEL CLAD t ) 08 BRONZE ( ) 09 COMPOSITE ( D 10 NON-METALLIC <br /> ? f 1 12 LlUKNOWU c ) 13 OTHER: <br /> 43x'04-070185 _ . PAGE 1 <br />