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STATE ID NUMBER T-� <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 /THOS NEN PERMIT 1 ) 05 RENEWED PERMIT 1 ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) -I <br /> 1 1 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT 1 ) OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER __ ---- <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AOINCY/ PUBLIC AGENCY ONLY <br /> �.1 1 � ,_„�,��q///S e Q l 1 Ol FED 1 1 02 STATEEl ) 03 LOCAL <br /> STREET ACDRESS /-LJCIT� STATE I'^� <br /> 149 28 �Ko!Z _ SIN <br /> II FACILITY <br /> FACILITY NAME _ DEALER POREMEN/SVPlR .{-+ j A0 -1*S <br /> L J�(, <br /> STREET ADC'ESS NEAREST CROSS STREET <br /> A- <br /> CITY � 5��3 CDVNTY cN ZIP <br /> - J <br /> MAILING ADORESS CITY STAT[ ZIP <br /> PHONE W,AREA CODE TYPE OF BUSINESS <br /> ( 1 01 GASOLINE STATION 1 1 02 OTHER <br /> --- --. ._ <br /> NUMBEP CF CONTAINERS PUPAL AREAS ONLY TONNSHIP RANGE SCCTION - <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> �DAYS: NAME'LAST NAME FIRST) AND PHONE W/AREA CODE NIOX TS: NAMEIIAST NAME FIRST) AND PHONE W/AREA COD! <br /> ——� L—Tc( 1 Z --- - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> -iV DESCRIPTION <br /> A. (/Y/01 TANK f 1 02 OTHER) CONTAINER NUMBER <br /> —70 A�01101< <br /> B. MANUFACTURER (IF APPROPRIATE): N J :YEAR MFG: C. YEAR INSTALLED f ) UNKNOWN0. CONTAINER CAPACITY: GALLONS 1 1 UWtMWWN E. DOES TNTAINER STORE: 1 1 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES l 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 01 UNLEADED l i 02 REGULAR l 1 03 PREMIUM ( _1 04 DIESEL ( 1 05 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TH ICY.NE55 OF PRIMARY CONTAINMENT: 1 ) GAUGE ( 1 INCHES 1 I CM l 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l ) 02 NON-VAULTED ( 1 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WALLED 1,({ 02 SINGLE WALLED 1 1 03 LINED <br /> D. ( 01 CARBON STEEL l ) 02 STAINLESS STEEL l ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 OS CONCRETE <br /> 1 ) 06 ALUMINUM l 1 07 STEEL CLAD (. 1 OB BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> -( 1 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-07018S PAGE 1 <br />