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STAFF ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> i --` <br /> Y1 1! 01 NEW PERMIT i 1 OS RENEWEO PERMIT I 1 07 TANK CLOSED ( } 09'DELFT€ FRCM FILE (NO FEE ) <br /> r-_1 02 COIIDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 4(i MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> N.t%t(CO00ORr.TION.INDIVIDU L aR FuaLlc ACENCYf ____J�PUBLIC AGENCY ONLY <br /> -- ( 1 O1 FED 1 1 02 STAT[ l ) 03 LOCAL <br /> SYp':ET AC'IREa CITY STATE ZIP <br /> II FACILITY <br /> FACItIIT�YJ�Rk--(E DEAL/ESR/FOrP/E�MEENNISUPERVISOP <br /> --- <br /> STFEE/TACC'E$S NEAREST CROSS STPEET <br /> CITY COUNTY ZIP <br /> MAILING ADDPESS CITY STATE ZIP <br /> PHONE W•ACE• COME TYPE OF fSUSINESS <br /> _-- { 1 01 GASOLINE STATION ) 02 OTHER �jvPYt ��r7 <br /> _.. <br /> NUf-'5EQ PF CONTAINEV'S PUPAL AREAS ONLY TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NA",,EfLAST NAME FIPSTI AND PHONE W/AaEA CODE F,�(IHTS' NAMEILAST NAME FIRSTI AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (�) 01 TAHK ( 1 02 OTHER: CONTAINER Nt1HBE <br /> B. MANUFACTURER (IF <br /> APPROPRIATE <br /> YEAR MFG: C. YEAR YNSTALLEDJ i I UNKNOWN <br /> 0. CONTAINER CAPACITY: �- GALLONS t I UNKNOWN LE �OES THE CONTAINER STORE=-( 1 01 HASTE f 1 02 PRODUCT <br /> — --- - --Y-_. -�.—_-� <br /> F_ DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (;) 01 YES t i 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t 101 UNLEADED (v 02 REGULAR 1 1 03 PREMIUM l l 04 DIES L f I OS WASTE OIL 1 1 06 OTHER <br /> V CONTAINED CONSTRUCTION <br /> A. THICFtIESS OF PRIMARY CONTAINMENT: 1 1 GAUGE ( I INCHES 1 I CM I UNKNOWN <br /> I <br /> �B. [ 1 01 VAULTED iLOCATED IN At1 UtIDERGPOUND VAULT T)Ct 02 NON-VAULTED t 103 UNKNOWN <br /> JC. t I 01 DOUBLE WILLED ( 1 02 SI14GLE WALLED ( 1 03 LlttfO <br /> D. ( }� OS CARBON STEEL [ 1 02 STAINLESS STEEL f 1 03 FIEERGLASS I 1 04 POLYVINYL CHLORIOC f 1 05 CONCRETE <br /> �J•,•Y ! 06 ALUMINUM t I 07 STEEL CLAD t 1 09 BRONZE 1 1 09 COMP05ITE f 1 10 NON-METALLIC <br /> f 1 12 L-141'.NOWH ( 1 13 OTHER: <br /> PAGE 1 <br /> If,�.04-d i^185 <br />