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r✓I �,� STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> /01 NEW PERMIT 1 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 DELETE FROM FILE (NOFEE) <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INCIVIDUAL OR PUDLIC AGENCY) Pl1B LIC AGENCY ONLY <br /> O1 FED 1 1 02 STATE l 1 03 LOCAL <br /> liTPEfT AO^REBS CITY STATE IIPyn A✓' <br /> II FACILITY <br /> NCILITY NAY.f � � DEALER/FOPEMENfSUPEPVISOP <br /> _�vL'A �Jc..)/rT'iaAi GY�a-e✓�'17Y _ <br /> ":FEET ACCIESS NEAREST CROSS STREET�K;3 J• I�G✓d LC/✓li r 6C � � Lia/G <br /> 4ITY COUNTY / LIP <br /> Iz9AILING ADDRESS / CITY ST TE LIP <br /> 'OWE W•APEA CODE TYPE OF 5USIN.SS <br /> 01 GASOLINE STATION ( /1 .02 OTHER/,�;, <br /> (NUYOCR CF CDNTAINEPS TPUP AL AREAS ONLY TOWNSHIP RANGE ` Sf CT ION <br /> [ II 24 HOUR EMERGENCY CONTACT PERSON <br /> ^ATS: NAr.E(LAST NAME FIPST I" AND PHONE W/AREA CODE NIGHTS: NAMEILAST NAME FIRST) AND PHONE W/AREA CODE <br /> �es'vvy �o�� 1os -z¢Y 92zS <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> 01 TANK W11,02 OTHER_ CONTAINER NUMBER <br /> r / <br /> +1. MANUFACTURER (IF APPROPRIATE), �j/ YEAR MFG:A, rl C. YEAR INSTALLED IUNKNOWN <br /> U. CONTAINER CAPACITY: GALLONS (!/T tUMNOWN IE. DOES THE CONTAINER STORE: ( 1 01 WASTE l/fI 02 PRODUCT <br /> I>. <br /> DOE <br /> $ THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE PIL ? (rI 01 YES ( 1 02 NO IF YES CHECK, APPROPRIATE SOI(ES): <br /> (Al 01 UNLEADED 1 1 02 REGULAR 1 1 03 PREMIUM (/l 04 DIESEL ( 1 Oi WASTE OIL i 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> [A. THICKNESS OF PRIMARY CONTAINMENT: _ ( 1 GAUGE ( I INCHES ( 1 CM 4✓' UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l 1 02 NON-VAULTED "03 UNKNOWN <br /> IC. 1 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED l 1 03 LINED <br /> D. I 1 01 CARBON STEEL f ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> /1 1 06 ALUMINUM 1 1 07 STEEL CLAD ( 1 OB BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (,4 12 UNKNOWN l 1 13 OTHER: <br /> HBE04-071185 PAGE 1 <br />