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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> V ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 2 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 04 MINOR CHANGE lH0 SURCHARGE) <br /> I OWNER _ <br /> NAME COPeORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br /> snET�na,Ass carr STAT — uo <br /> o �� sszo <br /> II FACILITY <br /> FA 11111NAME DCALC FOR EME W'SUPERVISOR <br /> 1prCZ RUG hLTA�- t <br /> STREET ADD° 5 NEAR CEJ CROSS STREET <br /> ZIP <br /> CITY COV NT Y` _ <br /> l R <br /> -E S CITY STAXEE ZIP <br /> MAILING S" A DOPE t5 / C <br /> SAL 7 <br /> PHONE Wi APEA CODE EAREAS <br /> USINESS �K� ri�,,/ <br /> !_ ASOLINE STATION l 1 02 OTHER NUMBER OF CONTAINERS RURAY TOWNSHIP RANDE SECTION <br /> Z <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OcYS: NAMEfLAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE WiAREA CODE <br /> -s'a./ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( ) 01 TANK ( ) 02 OTHER: CONTAINER HU)'18ER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED /q I l ) UNKNOWN <br /> 0. CONTAINER CAPACITY: OOa GALLONS 1 ! UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> 1 ) 01 UNLEADED ( 1 02 REGULAR t ) 03 PREMIUM ( 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE f ) INCHES ( ) CM (LG UNKNOWN <br /> B. f ) O1 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (.*92 NON-VAULTED ( 1 03 UNKNOWN <br /> C. f 1 01 DOABLE WALLED ().d 02 SINGLE WALLED ( 1 03 LINED <br /> D. 01 CARBON STEEL E ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) OS CONCRETE <br /> 1 ) 06 ALUMINUM l ) 07 STEEL CLAD t ) 08 BRONZE l ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> t ) 12 UNKNOWN ( 1 13 OTHER: <br /> NSC04-070185 <br /> PAGE 1 <br />