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ti • y y//1W STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 01 NEN PERMIT ( 1 OS RENEWED PERMIT ( 1 07 TANK CLOSED 1 1 OV DELETE FROM FILE (NO FEET <br /> ( 1 0: CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NA M!ICOP-CRA T ION.I NO IV IDU IL DR FULL IC AGE (CYI PUBLIC AGENCY ONLY <br /> -_ ✓1 I- 1__ }�_ . 1 , \ J ��-rG`_ 1 1 01 FEB 1 1 02 STATE ( 1 03 LOCAL <br /> ST-!ET AMRESS CITY STATE ZIP <br /> II FACILITY <br /> J <br /> FACIA Y NAM1E 1 OEALER/FOPEMEN'SVPEPVISOP <br /> e I d <br /> 5-A-,-c-- _---- <br /> STFEET ACCESS Nf APEST CROSS STOEET <br /> CITY 0 COUNTY ZIP <br /> CJ C—o -5 a1c �ti `153.ao <br /> MAILING ACDPESS CITY STATE ZIP <br /> y_ - <br /> PHONE W•A-EA CODE TYPE OF DUSIN!SS <br /> l 1 01 GASOLINE STATION ( 1 02 OTHER <br /> NVYpf• CF CONTAINECS — — PVPAL -PEAS ONLY TGW`lSHIP -- PANGF SlCTION -- <br /> III 271 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LASI NAME /IPST I AND PHONE W/APEA CODE NIGHTS: NAMF(LAST NAME FIRST)-ANO PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ()(j 01 TALK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE)! YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: cc c; GALLONS 1 1 UNKNOWtI E. OOE5 THE CONTAINER STORE: ( 1 01 WASTE V\I 02 PRODUCT <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOK(ES1: <br /> I 1 Ol UNLEADED ( 1 02 REGULAR 1 ) 03 PREMIUM ( 1 04 DIESEL l 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> �A. THICKNESS OF PPIMARY CONTAINMENT: 1 1 GAUGE ( 1 INCHES 1 1 CM ( I UNKNOWN <br /> B. f 1 01 VAULIED (LOCATED IN AN UNOERGROUnO VAULTI 1A1 02 NON-VAULTED f 1 03 UNKNOWN <br /> IC. I 1 01 DOUBLE WILLED (XI 02 SINGLE WALLED I 1 03 LINED <br /> 0. f 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIGERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( 106 ALUMINUM 1 1 07 STEEL CLAD I 1 08 8ROIILE I 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 UNKNOW)) l 1 13 OTHER: <br /> N SC 04-070105 PAGE 1 <br /> Ls.. <br />