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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> NEW PERMIT ( ) 05 RENEWED PERMIT ( 07�aE0 ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ) 08 0 CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMEfCOPPOR AT ON.I NOIV IDUAL OR VBl C AGENCY) PUBLIC AGENCY ONLY <br /> Ol FED 1 02 STATE Ufl'03 LOCAL <br /> STREET ADDRESS _--f ^^ CITY STATEI�� <br /> — - – <br /> zlc <br /> II FACILITY <br /> FACI ITY NAME I DEALER/FOPEMEN/SUPERVISOR <br /> G rPhC� S <br /> STRCET PDD PESS . <br /> oo- <br /> NEAP.Eb CROSS STREET <br /> CITY-.- COVNTY ZIP <br /> calm no J o <br /> S. <br /> MAILING ADOPESS CITY STAT ZIP <br /> `L H Co <br /> PHONE��Wp//ACEA CODE TYPE OF BUSINESS ,� � ' <br /> �3NT Qb 3�0 ( 1 01 GASOLINE STATION ( ) 02 OTHER. SC$1,071 <br /> NUMBER OF CONTAINERSRUPAL AREAS ONLY TOWNSHIP PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS' NAME( AST NAME fIR5T1 ANO PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PNONE W/AREA CODE <br /> I'}1`Ccu.2 x9�bsr 00to 3b5 q 3z� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( O1 TANK f l 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: SSO GALLONS l ) UNKNOWN E. ODES.THE CONTAINER STORE: f 1 01 WASTE W 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? Q0 01 YES f ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)- <br /> ( ) 01 UNLEADED 04 02 REGULAR ( ) 03 PREMIUM ( 1 04 0 ) 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( l INCHES ( ) CM UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1Q 02 NON-VAULTED f ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED S&.02 SINGLE WALLED 1 ) 03 LINED <br /> D. 1 ) 1 CARBON STEEL l ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( l 08 BRONZE 1 l 09 COMPOSITE f ) 10 NON-METALLIC <br /> l ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> ✓ Y <br />