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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f Q1 NEW PERMIT I 1 05 RENEWED PERMIT ( ) Oi TANK CLOSED f T 09'OELETE FROM FILE (NO FEE ) <br /> 0, COIIOITIONAL PERMIT f 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER f1 <br /> NtY*tCO'bPCPATION,iNCIVIDU4L OR FUDLIC AGENCY) fes.,.`-------! -.a ! �j PUBLICAGENCY ONLY <br /> `-Cl i/ l• 1 ! O1 FED 1 ! 02 STATE ( 1 03 LOCAL <br /> STa•ET AT:'14ES3 ��/��� CITY STATE �7 <br /> II FACILITY <br /> FACILITY N+r,E—_ CUe OEtIER/FOPEt1EN�SVRERVISOR -- <br /> STeEET ACL`'ESS NEAPESY CPO$$ IX <br /> PEET <br /> CITY <br /> COVNTY 'J✓" /`^' ►'" /-A ZIP <br /> MAILING ADDRESS CITY [J $TATC ZIP <br /> ,Plq-",c: z 14 --i. yr e S%/4�✓ r �/ zo ' <br /> PMOL+'! WsArEt C -DVSINESS <br /> 7 !�- 'C! i 1�01 GASOLINE STATION f 1 02 OTHER <br /> NUYDER CR C?kTAINEaS � -� RURAL AREAS ONLY ; TC�Wf1SHIP -- RANGE-- SECTION <br /> III 2ri HOUR EMERGENCY CONTACT PERSON <br /> DAYS: ,NAKEFIRS, A' pN AREA COONION75: NAMC(LAST NAME FIRST) AND PHONE4liAPEa CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. { 01 TAtIK f 1 02 OTHER` (CONTAINER NUMBER ��T_— ------_----- <br /> B. MAIIUFACTUP.ER i IF APPROPRIATE 1: LE �O!S <br /> YEAR MFG: C. TEAR INSTALLED 1 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: IppU GALLONS 1 I LINKNOWt( THE CONTAINER STORE: 1 1 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE t10TOR VEHICLE FUEL OR WASTE OIL ° t 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOXIES): <br /> 1 1 01 L1;tLEADED { i 02 REGULAR t 1 03 PREMIUM i 1 04 DIESEL 1 1 05 WASTE OIL 1X 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TMICFNESS OF PPIMARY CONTAINMENT: f I GAUGE f I RICHES f 1 CM 0, UNKNOWN <br /> B. I 1 01 VAULTED 1 LOCATED IN AN Ut10ERGPOUND VAULT I 1 1 02 NON-VAULTED- 1 1 03 UNKNOWN <br /> !C. 1 1 01 DOUBLE WtLLEO V1 02 SINGLE WALLED f 1 03 LINED <br /> �0. t 1 71 CARBON STEEL f 1 02 STAINLESS STEEL I 1 03 FII;ERGLASS f 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> f I OF ALUMINUM 1 1 07 STEEL CLAD 1 1 08 BROIIZE f 1 09 COMPOSITE f f 10 NON-METALLIC <br /> i t 12 UNKNOWN f 1 13 OTHER: <br /> 11S!:04-0:^185 PAGE 1 <br />