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• • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Ol NEW PERMIT t 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED ( 1 09•DELETE FROM FILE (NO FEET <br /> 1 1 02 COUDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER ------ ---- -- ---- - - .. <br /> Nw.t(CODPORATION,INDIVIDUAL OR FUSLIC AGENCY ) PUBLIC AGENCY ONLY <br /> S 1 1 O1 FEB 1 1 02 STATE ( 1 01 LOCAL <br /> _ STATE 2IP <br /> STOEf/T AaMRE" /q y� ��,�1 ��///./p� IIrCITY ALI � i�IµAA IIIc Q- <br /> _. C1(: ,1rY�J:L�w _LLSCt - ..L_-1 :�� <br /> II FACILITY _ -- <br /> FACILITY NAME �' DEAtER/FOPEMEN/SVPERVISOD <br /> STPEET ACC'E$S NEAREST CROSS STREET <br /> CITY COUNT , IIP y�5+ <br /> C TY ST�� ZI( � <br /> ' M�INC AD vFty — <br /> PHONE WIAFEA CODE TYPE Of BUSINESS <br /> 101 GASOLINE STATION (W.02 OTHER <br /> NUMBER CF CONTAINERSPUPA) AREAS ONLY TOwNSN2P RANGE SCCTION <br /> III `24 HOUR EMERGENCY CONTACT PERSON <br /> DAY NAME(LAST NAME fIPSTI AND PHONE W/APEA CODE FONTS: NAME(LAST NAME FIRSTI AND PHONE WIAPEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION _ ----- --- <br /> A. 1-fl 01 TANG( 1 ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> 1 [7- 1 1 <br /> D CONTAINER CAPACITY: /?-Igo GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE (V) 02 PRODUCT <br /> T_—___ <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 ) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> I ) 01 UNLEADED 1 1 02 REGULAR l 1 03 PREMIUM Ml 04 DIESEL 1 1 OS WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION _._._ ....- <br /> �A. TPICP.NFSS OF PRIMARY CONTAINMENT: 1 1 GAUGE ( 1 IIICHES 1 1 CM l(L) UNKNOWN <br /> IB. I 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT)--1( ) <br /> ) 02 NON-VAULTED 1 1 03 UNKNOWN <br /> 1C. I 1 Ol DOUBLE WILLED l 1 02 SINGLE WALLED 1 1 03 LINED - - <br /> D. 1101 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 06 ALUMINUM l 1 07 STEEL CLAD 1 1 OB BROtIZE 1 109 COMP051TE ( 1 10 NON-METALLIC <br /> 1 12 UI!KNOWtl t 1 13 OTHER: <br /> . - - - ___ __ -___. - -- PAGE 1 <br /> H5C04-07n185 <br /> r � <br />