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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 OELETC FROM FILE (NO FEEL <br /> 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE IND SURCHARGE) <br /> I OWNER <br /> NAM•_(COPPORATION.INDIVIOUAI OR PUBLIC AGENCY) ///''' PUBLIC AGENCY ONLY <br /> �y l 1 01 FED 1 1 02 STATE l 1 03 LOCAL <br /> TPECT ACORESS ` CITY ST ZIP <br /> 6urra»I orsl+�+ •- St Ict�T G. �'F�F9 IGT D ��, t� Y - Is Z og <br /> 1 <br /> II FACILITY _ <br /> FACILITY NAME DEALE�R//FOPEMENISUPEPVISOP <br /> l � m /J �Je (� �! � cr9'1y/O�nn �rrl✓P� <br /> STREET AODPESS NEAREST CROSS STREET <br /> b-2-12r <br /> C. <br /> COUNTY I ZIP <br /> S/ouCtoAJ � Sa^'� �GL. <br /> MAILING ADDRESS CITY <br /> STZIP <br /> �—fa c, Te1L <br /> PHONE W%ATYPE OF BUSINESS �/ <br /> L15 _ ( 1 01 GASOLINE STATION K) 02 OTHER <br /> NUMBER CF CONTAINIIEPS RUP AI APE AS ONLY : TOWNSHIP RANGE SECTION <br /> _.. oz���_ <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAMEIlAST NAME fIPiT1 A D PNONE W/AREA CODE NIGHTS: �e SLA NAME FIRST) AND PHONE W/AR Cf <br /> 7-9 17 a Ing 1(CJ log \» 9 <br /> COM"ETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> " c A. I f 1 02 OTHER: CONTAINER NUMBER I <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY:_I O D r) GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE (X1 02 PRODUCT —_ <br /> F. DOES THE CONTAINER, STORE MOTOR VEHICLE FUEL OR WASTE OIL T 1 0 YES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( 1 O1 LAILEADED 1 02 REGULAR 1 ) 03 PREMIUM l 1 04 D L ( 1 05 WASTE OIL 1 1 06 OTHER <br /> _— <br /> V CONTAINER CONSTRUCTION y <br /> IA_ TP.ICKNESS OF PRIMARY CONTAINMENT ( 1 GAUGE l 1 INCHES ( 1 CM �\AWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 'VXI VAULTED 1 1 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WALLED (X SINGLE WALLED 1 1 03 LINED <br /> D. ( 1 01 CARBOU STEEL 1 1 02 STAINLESS STEEL f I D3 FI6ERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> l 1 06 LUMINUM 1 1 07 STEEL CLAD 1 1 08 BRONZE I 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 NKNOWt7 ( 1 13 OTHER:...... <br /> _. _ _...--_._.___—_— —_-- -- PAGE 1 <br /> H3C04-070185 <br />