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ID-et <br /> b STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 05 REWEWED PERMIT 07 ED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 01 NEW PERMIT <br /> L—_ %2 CONDITIONAL PERMIT 1 1 0 AMENDED PERMIT ) 08 NoCHANGE (NO SURCHARGE] <br /> I OWNER <br /> PUBLIC AGENCY ONLY <br /> NAME CORPOR AT IO LINO IVID VAI OR PUBLIC ADEN Y)I ( ) 01 FED 1. 11 02 STATE &h6 03 LOCAL <br /> 7ri Icy- <br /> CITY STAT II� <br /> STREET ADDRESS a <br /> 7A/7y <br /> ( w� <br /> II FACILITY _ <br /> FACI TY NAME >, DEALER/FOREMAN/SUPERVISORS / <br /> 1 e-�_�c� ►.�rencc. j� 1/��n S( eri�'�e�v�' <br /> NEAP" CAO STR FST <br /> STREET�� ESS . /' <br /> CITY (,�{l COU NJo 1 LI��1� <br /> CITY 5 STATE ZIP <br /> aa <br /> MAILINGORES� 1/• <br /> 111111 camQ—_—_ -. a <br /> PHONE W/AREA CODE TYPE OF BUSINESS ScfLCQ <br /> DE ♦ ( 7 01 GASOLINE STATION ( 02 OTHER �lao" i _ <br /> 3 f0 <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS:�E(LA T NNAAME FIRST) AND PHONE W/AREA CODE NIG TS: N` (sA T NAME FIRST) AND PHONE W/AREA CODE <br /> n -3lo�-Olo3 G <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> 01 TANK f l 04 OTHER: CONTAINER NUMBER <br /> A. (� <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: /aLV GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE (&02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ?.o1 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXIES): <br /> ( ) Ol UNLEADED 1 ) 02 REGULAR ( 1 03 PREMIUM L14 04 DIESEL ( ) 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CMUNKNOWN <br /> e. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Qg 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t ) 01 DOUBLE WALLED ( 02 SINGLE WALLED l ) 03 LINED <br /> D. f ,} CARBON STEEL l 1 02 STAINLESS STEEL l 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> f ] 06 ALUMINUM l 1 07 STEEL CLAD l ) 08 BRONZE ( ) 09 COMPOSITE ( l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> NSC04-070185 <br />