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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> �O1 NEW P IT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 7 02 CO HAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> NAME( RPORAT20 INOIV`IP UAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> id n ( 1 01 FED l ) 02 STATE _LPO 03 LOCAL <br /> STPEET ADDRESS I 1- - CI y I 1 ,� STA <br /> ( SVN'C_/�'-/Y�/• L/L?-Vim <br /> II FACILITY <br /> FACILITY N E DEALaR/FOREMAN/SUP ERVI <br /> CMw )vers <br /> STREET ADDRESS NEAREST CROSS STREET <br /> Commerc e <br /> CITY COU TY . ZIP <br /> S4c,--K-46n 7o0- w yyTT1 <br /> MAILING ADDRESS C TY/f ) / S� <br /> PHONE W/AREA ACO'D/E TYPE OF BUSINESS /- <br /> 9� /7� �5�� ( 1 01 GASOLINE STATION <br /> _!,<) 02 OTHER <br /> BER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> II 24 HOUR EMERGENCY CONTACT PERSON <br /> DA1' :i NAME(LAC$�NAME FIRST) AND PHONE W/ARE&� E NIGHTS: 0.MerAME FIR STI AN�PW��v00 <br /> COMPLETE THE FLIOLLLLOOWIING ON A SEPARATE FORM FOR EACH CON�T/A-INER <br /> IV DESCRIPTION <br /> A. ( 01 TANK ( 1 04 OTHER: CONTAINER NUMBER �- �1 <br /> B. MANUFACTURER IIF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED I71pC)1 ) UNKNOWN <br /> D. CONTAINER CAPACITY: � GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (14-02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (,kepi YES 1 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( 1 02 REGULAR ( 1 03 PREMIUM (>d 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT• 1 ) GAUGE ( 1 INCHES ( ) CM UNKNIOWN _ _ <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) LT02 MON-VAULTED ( ) 03 UNKNOWN <br /> C. l ) 01 DOUBLE WALLED (S2 SINGLE WALLED l 1 03 LINED <br /> D. ?�1 CARBON STEEL ( 102 STAINLESS STEEL 1 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE f ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: _ <br /> PAGE 1 <br /> HSC04-070185 <br />