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STATE I0 NUMBER T <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK I <br /> (A 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 DELETE FROM FILE IND FEE) <br /> 1 ) 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT 1 1 OB MINOR CHANGE INO SURCHARGE) - - <br /> I OWNER _- ----- -- - <br /> HAME(COPPORrTION.INCIViIDUAL OR PPUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> —M t4 pAQP Gw 1 ' p�Z�SLs 1 1 Ol FED 1 102 STATE l 1 03 LOCAL <br /> STREET ACTRESS W I CITY <br /> STATE ZIP: <br /> S c.�- <br /> zo <br /> II FACILITY _ <br /> rFACILITfNAY,! - /' DlALFR/FnRnIN;SV �SS NEAREST CROSS STREET <br /> P§r_lo -�'f l / �—rj /A, ^ _ COUNTY I ) 2IP <br /> MAILING ADDRESS CITY STATE ZIP <br /> PHONE W PEA CODE TYPE OF BUSINESS <br /> 1 01 GASOLINE STATION 1 1-02 OTHER <br /> NUMBER Cl CO N_TIAI NIPS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NA E)L ST NAME FIRST) AND PHONE W/APEA COD! NI�TS: NAMg(LAST NAME FIRST) AND PHONE WIAREA CODE <br /> �� Al <br /> �2 qyy f�3 I -Z0`1 9 �fy-i-��a <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (24 01 TANK 1 1 02 OTHER: CONTAINER HLMER <br /> 1 q -70 OIti4>11 I <br /> B. MANUFACTURER (IF APPROPRIATE): U NIC- YEAR MFG: C. YEAR INSTALLED 1 ) UNKNOWN <br /> 0. CONTAINER CAPACITY:/o, 0047 GALLONS 1 ) UNKNOWN E. DOES THE.CONTAINER STORE: ( 1 01 WASTE 1 ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE -MOTOR VEH�IC�LE FUEL OR WASTE OIL ? l 1 01 YES 1 ) 02 NO IF YES CHECK APPROPRIATE SO%(ES): <br /> 1 ) 01 UNLEADED I ) 02 REGULAR iTS�03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL I 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 ) GAUGE 1 1 INCHES 1 ) CM 0(UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l ) 02 NON-VAULTED 1 1 03 UNKNOWN <br /> C. ( 11 01 DOUBLE WALLED 1 02 SINGLE WALLED I ) 03 LINED <br /> D. lip 01 CARBON STEEL 1 1 02 STAINLESS STEEL I ) 03 FIBERGLASS I ) 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 1 OE ALUMINUM 1 107 STEEL CLAD 1. ) OB BRONZE 1 1 09 COMPOSITE 1 ) 10 NON-METALLIC <br /> _( ) 12 UNKNOWN ( 1 13 OTHER: — <br /> HSC04-070185 PAGE 1 <br />