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! 3 . 1 <br /> L• �� <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 ) 01 NEW PERMIT t 1 05 RENEWED PERMIT 1(A 07 TANK CLOSED 09 DELETE FROM FILE (NO FEE) <br /> C 1 02 CONDITIONAL PERMIT I 1 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (NO SURCHARG <br /> I OWNER _ <br /> NAME COPPORATION,INDIVIDUALfOR PUB IC AGENCY) + t-u <br /> BLIC AGENCY ONLY <br /> E G coc0.� - {!i l!�O�Y\�,�' t `T J 01 FED ! 1 02 STATE ! 1 03 LOCAL <br /> STPEET AD^KESS ` l CITY L STATE ZIP <br /> II FACILITY <br /> F CILITY NAME �r� � ��� PE N/SUPERVISOR <br /> �t c- Coe 5+ X06 �r �l <br /> STREET ACL�"ESS NEAREST CROSS STREET <br /> CI `-b C r\ u� F�CWHTY ZI I s a t V <br /> MAILING ADDRESS CIT Yi ,� ! S�TATT'E�, ZIP <br /> PHONE W,ACEA CODE T)PE OF BUSINESS <br /> -xq- C� I 01 GASOLINE STATION .0 OTHER <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 2rr HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NA t�LAST NAM($ FIPSTI AND PqflN ARE'4q I N TSS'. N�IE( LAST NAME FIRST) AND PHONE W/AkE/A CO14 — OL <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. r/Q 01 TANK ! 1 02 OTHER --^ CONTAINER MUMMER <br /> B. MANUFACTURER CIF APPROPRIATE): YEAR MFG: C. YEAR TNSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: L1pQ GALLONS ! T UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE A) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WAST OIL ?/pl� 01 YES C 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> C 1 01 UNLEADED C 1 02 REGULAR ! 1 03 PREMIUM 04 DIESEL 1 J 05 WASTE OIL ! 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: I ) GAUGE ( J INCHES ! 1 CM i 1 UNKNOWN <br /> B. I 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 9 02 NON-VAULTED ( 1 03 UNKNOWN <br /> JC. f 1 01 DOUBLE WALLED 02 SINGLE WALLED 1 1 03 LINEDD. P" 01 CARBON STEEL ! 1 02 STAINLESS STEEL ! 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ! 1 05 CONCRETE <br /> 11 06 ALUMINUM l 1 07 STEEL CLAD C 1 08 BRC117E C 1 09 COMPOSITE 11 10 NOM-METALLIC <br /> ! J 12 UNKNOWN ( l 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />