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y,. `0, STATE-I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK .- <br /> ^- 1 1 09 DELETE' FROM FILE (NO FEEI <br /> y F+ul NEN PERMIT l I OS RENEWED PERMIT 1 1 07 TANK CLOSED <br /> 1 1 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT t 1 00 MINOR CHANGE (N0 SURCHARGE) <br /> I OWNER <br /> ---------- PUBLIC AGENCYONLY <br /> NAY.-lCOPPORATION.INDIVIDUAL OR FUSLIC AGENCY) ( 1 01 FED ( ) 02 STATE l 1 03 LOCAL <br /> y <br /> STREET <br /> CITYII <br /> ADnPESS ` - ST J{ c L` 7 <br /> ..- 127 <br /> II FACILITY <br /> FACILIIN/AME L DEALER/FOPEMEN/SUPERVISOR <br /> ��`v G���.4 s/�•�-�. Gee(..... VL ��- <br /> STREET ACV-ESS NEAREST CRpf3 STREET <br /> --/ zIP <br /> CITY COUNTY / <br /> f� MAILING ADOPESS CI <br /> $T TE IIF <br /> TY <br /> ti . S3Z9 <br /> PHONE W%AREA CODE TYPE OF BUSINESS <br /> _0 tGASOl2NE STATION f OTHER <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY TOWNSHIP PANGF SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OAY NAM.E(LAST NAME FIPSTI AND PHONE W/AREA COVE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> T COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION --__- <br /> "iI. A. f07 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> � <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG C. YEAR INSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY:f GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE- 1 1 01 WASTE_,fC 02 PRODUCT <br /> F. OES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 ) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> 1 U1ILEAOED 1 ) 02 REGULAR 1 ) 03 PREMIUM f 1 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER__ <br /> V CONTAINER CONSTRUCTION <br /> A. <br /> THICY,NESS OF PRIMARY CONTAINMENT: —_1 1 GAUGE f 1 I1ICHES 1 1 CM -Ulk-iRACNDWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND] VAULT) >4.02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE W4LLE0 ,'Q 02 SINGLE WALLED l 1 03 LINED <br /> D. 1 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM l 1 07 STEEL CLAD ( ) OB BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER -- <br /> �....____.___.__-_-__ --- PAGE 1 <br /> HSC04-070185 <br />