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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> PEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 42 COHDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) Oq MINOR CHANGE (NO SURCHARGE) — <br /> I OWNER <br /> NAME(CCPPCRATION,INDIVIDUAL OR FULIC AGENCY) PUBLIC AGENCY ONLY <br /> Co ri+( T u c-K_t a-L G ( ) 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> STREET ADOREZS CITY STATE ZIP <br /> L o o rrL S S-1-0 c k ►-, C-ft 9 s OIL55 <br /> II FACILITY <br /> FACILITY NAME S DEALER/FOPEMEN./SUPERVISOR <br /> T <br /> STREET ADL'?ESS NEAREST CROSS STREET <br /> a Wo O l.._o©m t s 'R..9. q <br /> CITY 40CODUNNTY ZL <br /> MAIL NG ADDPESSJ CITY STATE ZIP <br /> PHONE,ttWoiA=EA C DE TYPE OF BUSINESS <br /> 5cib 1 ( ) 41 GASOLINE STATION 02 OTHER f IZ1eC'�j�(l� <br /> NUMBER OF CONTAINEPS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> PAYS: NAMEfLAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(IAST NAME FIRST) AND PHONE W/AREA CODE <br /> Goodr-Lch bo as G Xj -qqg-L) D3 (10011ric K QOrrald 20 l -94$- 1,571 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORA FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ()G 01 TANK ( ) 02 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLED /r-??- ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: ted QQ GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE-' (If,) 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ('d 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)= <br /> f 1 01 UNLEADED ( ) 02 REGULAR ( ] 03 PREMIUM ( ) 04 DIEM ( 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( ) INCHES ( ) CM (j() UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ' 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f ) 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE 1 ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> &12 UNKNOWN ( ) 13 OTHER <br /> HBC04-070185 PAGE 1 <br />