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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (Jd 01 NEW PERMIT f 1 05 RENEWED PERMIT ( 07 CL '' Ib Ir ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT OQ MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP PORATI N.INDIVIDVAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY "� <br /> CI Fl <br /> 01 FED ( 1 02 STATE ry 03 LOCAL <br /> STPEETADD>REZSS 7,,1I fir CITY STATE <br /> p �` / �• ,f IU'(�Y K a _ �YL�� ZI�LZ <br /> II FACILITY <br /> RACIIITY NAME _ Q�I DEALER/FOREMEN/SUPERVISOR <br /> 1 11 U - 1� <br /> STREET ADDRESS NEAP.ES�ROSS STREET <br /> 2 5 <br /> CITY COUNTY IIP <br /> Glemen`� s man 5`00. <br /> `176, 7 <br /> DP ESS �` CITr LIee <br /> ,wmx+ `/-��T <br /> STATE ZIP rZZ T <br /> PHONE W/A.EA CODE 1 TYPE OF BUSINESS I`c <br /> ( ) Ol GASOLINE STATION (I(1—.02 OTHER Fire 1r,e. <br /> NUMBER OF CONTAINERS RVPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 yN �E zZ <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIDM iS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> En o� �9 33i/ ej 33 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION �J <br /> A. (SCJ 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 190 C. YEAR INSTALLED /9SD ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 4%t* GALLONS ( ) 11M(NOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE OKf 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 ) 01 UNLEADED l ) 02 REGULAR ( ) 03 PREMIUM tkf 04 DIESEL ( ] 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f l INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (XI 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED 06 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> I ) 06 ALUMINUM ( ) 07 STEEL CLAD f ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> �, r <br />