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. • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK______________—7 <br /> 1 1 01 NEW PERMIT l 1 05 RENEWED PERMIT 1 l 07 TANK CLOSED I 1 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 0A MINOR CHANGE (N0 SURCHARGE) <br /> L OWNER -- <br /> {-"------"-"-- PUBLIC AGENCY ONLY <br /> ,m AM!,COPPCPATION. NOIVIDUAL OR CVBLIC AGENCY) ( 1 01 FED ( ) 02 STAT ( ) 03 LOCAL <br /> -- ra -- -- -- ---- <br /> �STCEET ACCRESS <br /> 7:11,11TV STATE SfLP�� <br /> II FACILITY <br /> p DEALER/FOPEMEN/SVPEPVISOP <br /> kF ACI TY AME <br /> ggi yT-J � AfI I �a � Z�� <br /> g ' <br /> IS-TEE <br /> ENEAP.1`ST CROSS STREET <br /> _ EE ��n�a� l�cl _I( f <br /> COVNSIP <br /> CITY <br /> yY. J, <br /> 06( <br /> --- CITY^ I I� STATE ZIPS <br /> MAS NG ADDPESS v\'�1 CglIJ/QI– <br /> _1113 _ <br /> PHON W•APEA r TYPE OF BUSINESS <br /> ( ) 01 GASOLINE STATION f 1 02 OTHER <br /> NVMBEP CF CONTAINECS RV.AL APEAS ONLY : TOWNSHIP – PANGE SECTION <br /> III 24 HOUR EMERGENCY CONIACT PERSON <br /> ((DAYS: NA r.ElLAST NAME FIRST) AND PHO E /AREA CO/DE/ ? NIGHTS: NAME(LAST NAME FIRST) AND PHONE WIA EA CODE <br /> L__F f Q_hal- .._ a u ( 1/� 6 L^ J F0.r�? 1 a �O(A (S - -..—_-_—_ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 O1 TAIIK f ) 02 OTHER: CONTAINER NUMBER <br /> -- - <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1 1 UNKNOWN <br /> �0. CONTAINER CAPACITY: a-QQQ GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE- f 1 01 WASTE 1 1 0 PRODUCT - <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WAST OIL ? YES f ) 02 NO IF YES CHECK APPR PR IATE BOX(ES): <br /> 1 1 O1 UNLEADED ( 1 02 REGULAR l ) 03 PREMIUM 04 OI L 1 1 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION ----- <br /> ------------- ---------- <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES I 1 CM ( ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. l DOUBLE WILLED ( 1 02 SINGLE WALLED I 1 03 LINED <br /> D. 7 O1 CARBON STEEL l 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 1 0E ALUMINUM l ) 07 STEEL CLAD l 1 08 BRONZE 1 1 09 COMPOSITE ( ) 30 NON-METALLIC <br /> I f 1 12 UIiKNOWII ( 1 13 OTHER: --- <br /> PAGE 1 <br /> HBC04-07^185 <br /> , <br />