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No/ STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> l�l O1 NEW PERMIT ( 1 05 RENEWED PERMIT l 1 07 TANK CLOSEO l 1 09 OELETE' FROM FILE (HO FEET <br /> 'p, 02 CONDITIONAL PERMIT 1 106 AMENDED PERMIT 1 1 05 MINOR CHANGE IND SURCHARGE) <br /> I OWNER _ -- <br /> MAtICOPPORAT IOH.INDIVIOUAL OR FUOLIC AGENCY) Pl1BLIC AGENCY ONLY <br /> Y. <br /> 1 Ol FED 1 1 02 STATE 1 1 OS LOCAL- <br /> !r. l`F- <br /> CITY STAJ{� 21P <br /> Dn � <br /> sroseT ARE�,+ C <br /> II FACILITY — <br /> FACIL TY NAME DEALER/FOPEMCNI UPEPVISOP <br /> STREET ADD-ESS NEAREST CROSS S-ZPEET <br /> CITY -- COUNT IIP r <br /> MAILING ADOPESS CITY S 6TE ZIP <br /> C- L� <br /> PHONE W'APEA CODE TYPE OF EUSINESS rL�1 <br /> _ ( 1 O1 GASOLINE STATION '�" 02 OTHER <br /> NUMDEP CF CONTAINCRS PUPAL APEAS ONLY TON NSNIP PANOf SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS' NAY.CNIA T NAME PIPSTI AND PHONE W/APEA CODE NION TS: NAME(LAST NAME FIRST) 400 PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> >g A. 1 01 TANK ( 1 02 OTHER CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG:- C. TEAR INSTALLEDS l 1 UNKNOWN <br /> -- :— <br /> D. CONTAINER CAPACITY_ GALl0N15 ( 1 1UNKNOWNE. GOES THE CONTAINER STORE: 1 1 01 WASTE l�+/02 PRODUCT <br /> F. 00 S THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ()0 01 YES l 102 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> Cy) 01 UNLEADED ( 1 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESTE ( 1 05 WASTE OIL t 1 06 OTHER <br /> _— <br /> V CONTAINER CONSTRUCTION <br /> II4rA. THICY.NESS OF PRIMARY CONTAINMENT: 1 1 GAUGE ( 1 INCHES 1 1-CM lXUwHOWN <br /> 1 -.__ <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) .Tyj 02 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE W1LLE0 !J) 02 SINGLE WALLED 1 1 03 LINED <br /> D. (14,101 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 08 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> l 112 UNKNOWN l 1 13 OTHER: -.--- <br /> ..___._..__--_—_—_—. .____— PAGE 1 <br /> HSC04-070185 <br />