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STATE ID HUM Q�� �I�4I� <br /> APPLICATION FOR PERMIT TO OP ATE UNDERGROUND STOR E TANK <br /> 1 1 01 NEW PERMIT 1 1 05 RENEWED PERMIT 1 07 TANK CLOSED 1 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 COIIDITIOHAL PERMIT 1 1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER 1��H c Jr.M• �/t� SO •J _ <br /> NAY.!(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 ) 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br /> STREET A"PESS CITY STATE 2IP <br /> 300 1DAVEY_G4E�QD X3423 r gELMoU i ('.4 C?404 Z <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPEPVISOP <br /> hlA2eFrousE <br /> STREET ACD-ESS NEAREST CROSS STREET <br /> _i-t god_ C�unncoNex R9• � j4wvv/�r_12o e • <br /> CITY - - --_� 'COUNTY IIP <br /> MJTIE-N • _ -9A--AJ J"�RQu lel/ � S`33lo <br /> MAILING ADDRESSCZTY STATE IIP <br /> ---- 3ogVt� 61�lJ P� 342 lStLM0AIT GF R �loa2 <br /> PMON! W•APEA CODE TYPE CF BUSINESS <br /> __--- -0161 1 1 01 GASOLINE STATION (7(I 02 OTHER <br /> NLMB[P __ <br /> CF CONIAI VE RS---- - PORAL AREAS ONLY TOWNSHIP --- RANG! SECTION — <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM.EILAST NAME FIPSTI ANO PHONE W/AREA CODE NIGMTS: NAME(LAST NAME FIRST) AND PHONE W/AREA COO! <br /> � eisuA/ PM - =4�—�zov_ �eS®N , 2a-LPM -41 618 -01 <br /> �/ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> it DESCRIPTION <br /> A. 06 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> 0 MANUFACTURER IIF APPROPRIATE)% YEAR MFG: - C. YEAR INSTALLED yq t 1 UNKNOWN <br /> 10 CONTAINER CAPACITY: $S--U GALLONS t ) UNKNOWN E. DOES THE CONTAINER STORE 1 ) 01 WASTE (aO 02 PRODUCT - <br /> F. DOES THE CONTAI14ER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 00 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> I 1 01 U)LEADED ( 1 02 REGULAR 1 1_03 PREMIUM _()# 04 DIESEL ( 1 05 WASTE OIL 1 106 OTHER <br /> V CONTAINER CONSTRUCTION <br /> FL <br /> ICY.NESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES 1 1 CM 1 ) UNKNOWN <br /> 1B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULTS 17(1 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> C. 1 1 01 DOUBLE WALLED (A 02 SINGLE WALLED 1 1 03 LINEO <br /> D 1 1 01 CARBON STEEL l ) 02 STAINLESS STEEL (A 03 FIBERGLASS ( 1 04 POLYVPPLV1dMbtT"( 1 05 CONCRETE <br /> 1 1 06 ALUMINUM l ) 07 STEEL CLAD 1 1 06 BRONZE 1 1 09 COMPOSITE 1 IR4MEMFV18S18 <br /> l 1 12 UNKNOWN ( 1 13 OTHER: <br /> MSL04-070185 PAGE <br /> H <br /> ENVIRONMENTAL HEALTH <br /> P' AIT/SERVICES <br />