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. STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK Z <br /> 1 1 01 NEN PERMIT 1 1 05 RENEWED PERMIT 1(K 07 TANK CLOSED 1 1 09 DELETE' FROM FILE (NO FEE) <br /> 1 1 OA CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (HO SURCHARGE) <br /> [ OWNER <br /> NAME(COPPORATION.INOIVIOUAL OP PUOLIC AG f NCTI ,�• PUBLIC AGENCY ONLY <br /> A �-T �p 1 1 01 FED 1 ) 02 STATE l 1 03 LOCAL_ <br /> STeCCI AC7Rf5 /'TS � S, I�'i�� CITY 5 STAT( 2IP_S.� <br /> L//Tl\3>_ 9 <br /> II FACILITY _ <br /> FACILITY NAME Of ALER/rOPEMEN'SVPf RVISOP <br /> STREET ACC^ESS NEAREST CROSS STREET <br /> - 3 S_ Seo tts 7 _ <br /> CITY COUNTY S. T ZIP <br /> MAILINO ADDRESS CITY STATE ZIP <br /> RoX I `9Lf -7 �lzesrw 37/x' <br /> PHONE WIAPEA coot TYPE OF OUSINtSS <br /> l 1 01 GASOLINE STATION 1 1 02 OTHER <br /> HUM6f■ CP CONTAINERS RUP AI APE AS ONLY TOWNSHIP DANCE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NAY,E(LAST NAME PIRST) AND PHONE N/APEA COOL NIOHTS: NAMEILAST NAME PIRSTI AND PHONE W/AREA Coot <br /> _-AIw►�Ow , 0 ez, - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION p L __-- <br /> c A. 91 TAN 02 OTHER: ConlG� VaA-,,.. "J CONTAINER NUMBER <br /> r <br /> B. MANUFACTURER fIF APPROPRIATE)! YEAR MFG: C. YEAR INSTALLED _— 1X1 UNKNOWN <br /> 0. CONTAINER CAPACITY: /6 0rga GALLONS l ) UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE l ) 02 PRODUCT — <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 TES l 1 02 NO I YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 01 LPILEADEO 1 1 02 REGULAR l 1 03 PREMIUM ( 1 04 DIESEL l 1 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 1 INCHES 1 1 CM 1 1 UNKNOWN <br /> B. 1 1 01 VAULTED )LOCATED IN AN UNDERGROUND VAULT) '1 1 02 NON-VAULTED 1 1 03 L04KNOWN <br /> IC. l I 01 DOUBLE WALLED 1 1 02 SINGLE WALLED 1 1-03 LINED <br /> D. 1 1 01 CARBON STEEL 1 ) 02 STAINLESS STEEL 1 1 03 F16ERGLASS ( 1 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> 1 1 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 ORONZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> I_ .._1-1 12 UNKNOWN 1 113 OTHER: <br /> PAGE I <br /> IISC04-OiD185 <br />