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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) O1 NEW PERMIT l ) 05 RENEWED PERMIT (41 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 102 CONDITIONAL PERMIT ( 106 AMENDED PERMIT l ) OB MINOR CHANGE IND SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATIONDIVIOUAL OR PUBLIC AG€AICY) PUD LI GENCY ONLY <br /> •�- ( ) FED 1 ) 02 STATE C><03 LOCAL <br /> CITY STAT ZIP <br /> STREET ADDRESS S <br /> II FACILITY <br /> FA CII TY NAM ��` r DEALER/FORE /SURE VISOR <br /> Ja n — ( 5tL resr <br /> NEAREST OSS STREET , <br /> STREET ADDRESS <br /> 1-2yo 7_0J-JIB— <br /> DD _ IIP�S3�� <br /> CITY �VL. <br /> T <br /> �Q✓� V(� <br /> 6L4 a <br /> STATE ZI <br /> ca <br /> MAZIING ADDRESS <br /> ail <br /> PHONE W/AREA CODE TYPE OF BUSINE261?- <br /> _ ( ) Ol GASO STA N f�-02 OTHER � �/R <br /> p• / <br /> rcJ- <br /> NUMBER OF CONTAI/HERS <br /> RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT SOi4.-. _ <br /> DAY T NAME(LA NAME FIRST) AND PHONE W/A CODE NIGHTS' NAME( T NAME FIRST) AND PHONE W/AREA CODE <br /> 0 1 O <br /> COMPLETE THE FOL ING ON A SEPARATE FORM FOR CH CONTAINER <br /> IV DESCRIPTION <br /> A. (aYbl TANK ( ) 04 OTHER: CONTAINER R <br /> B. MANUFACTURER (IF APPROPR �E); YEAR MFG: C. YEAR IN LLED (W-UW(NOWN <br /> 0. CONTAINER CAPACITY: ;Lv,v GALLONS ( ) UNKNOWN E. GOES THE CONTAINER STORE: ( ) 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER ORE MOTOR VEHICLE FUEL OR WASTE OIL ? (I) 01 YES F _J02 NO IF YES CHECK APP PRIATE BOX(ES): <br /> ( ) Ol UNLEADED 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL 4-1, 06 OTHER <br /> V CONTAIN CONSTRUCTION <br /> A. THICKNESS 0 PRIMARY CONTAINMENT: f 1 GAUGE ( ) INCHES ( ) CM (,10 UNKNOWN <br /> O1 VA TED (LOCATED IN AN UNDERGROUND VAULT) (FT 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) O1 DOUBLE WALLED (19'02 SINGLE WALLED f 1 03 LINED <br /> D. ( )(0' CARBON <br /> ALU11ITNUM 1OI STAINLESS <br /> STEEL <br /> 08103 BRONZEFIBERG09SCOMPOSITE POLYVINYL <br /> NON-METALLIC( 1 05 CONCRETE <br /> (J.(f 12 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />