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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1�1 01 NEW PERMIT ( 1 OS RENEWED PERMIT 1 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT -( ) 06 AMENDED PERMIT 1 1 08 MINOR CHANGE INO SURCHARGE) -- - - <br /> I OWNER <br /> NAM.'EtCOO PORATTON NO VIDU41 OR PUBLIC DENCYI PUBLIC AGENCY ONLY <br /> 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br /> STREET 55 CI Y STATE IZP <br /> --- -._15 -�. F l aur ear S�rce� -71 <br /> U9- q b0 <br /> II FACILITY <br /> FACILITY NAME DEALER/ OPE ENCS VPERVISOR <br /> 93vr. <br /> r <br /> ES NEARES CROSS STREET <br /> T K)-��/11 COUNTY .. ZIP <br /> PESS CIT ATZIP <br /> A CODE TYPE OF BUSINESS <br /> 1 O1 GASOLINE STATION ( 102 OTHER <br /> NUMBED CF CONTAINIPS 2J RVPAL AREAS ONLY TOWNSHIP PA NGE SlCTZON <br /> LII 24 HOUR EMERGENCY CONTACT PERSON <br /> �CAYS: NAMEILAST NAME FIRST) AN PH X W/AREA CODE NIGHTS: NAMlIIAST NAME IRSTI AND P ONE 'AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 11V DESCRIPTION <br /> !,10K f 1 02 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED/f4?( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS 1 1 IAJKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 1x1 02 PRODUCT <br /> DOS THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL '+ f/Y� YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> ( 1 _ EAOEO ( ) 02 REGULAR l 1 03 PREMIUM 1 ) 04 DIF•SET-( 1 05 WASTE OIL J!OF-06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> [A __LHlCKNESS OF PRIMARY CONTAINMENT: OE 2 ( 1 GAUGE <br /> 1 XJlIEHES 1 1 CM 1 ) UNKNOWN <br /> 8. T 1 01 VAULTED (LOCATED IN AN LRIOERGROUND VAULT) (AL 02 NON-VAULTED ( ) 03 UNKNOWN - f_ <br /> 01 DOUBLE NkLLED 1 9A&_S_IFIGLE WALLED 1 ) 03 LINED <br /> LYtARBON STEEL I�IG02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 1 06 ALUMINUM l 1 07 STEEL CLAD 1 1 08 BROIIZE ( 1 09 COMPOSITE f 1 10 NON-METALLIC <br /> l 1 ,12 UNKNOWN l 13 OTHER: ---- <br /> HSC04-070185 PAGE 1 <br />