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STATE ID NUMBER <br /> APPLICATION 'FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> S 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT i ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> C ) 02 CONDITIONAL PERMIT 1 i 06 AMENDED PERMIT I ) 08 MINOR CHANGE (NO SURCHARGE) <br /> OWNER CIO 1 m Q I1gU6 (20 . <br /> NAME(COP'PORATION,INCIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> (�.O(A Pc)Cl,� ,Q JJJ/// / ( ) O1 FED 1 ) 02 STATE I ! 03 LOCAL <br /> STPEET AOnRESC?r' YV CITY fl[JCkSo� S/ T 2IY�R06 <br /> I FACILITY <br /> FACILITY NA1"E DEALER/FO EMEN/SUPERVISOR <br /> otiN et vwoTa�.s <br /> STPEET AOC'ESS NEAREST CROSS STREET <br /> -3 Al, /5 oA) <br /> FF COUNTY //�� ZIP /ZIr�}/ <br /> CITY k {�C-'�C�(�(lJ 17,x'jo V,� N p�([�IJ/L6 <br /> MAILING AODPESS 0k �zL � CITY ST TE ZIP <br /> PHONE W/ACEA CODETYRE CF BUSINESS <br /> , X � (.) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER CSF CONTAINEPS PUPAL AREAS ONLY : TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEtLAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(IAST NAME FIRST) AND PHONE W/AREA CODE <br /> te.)�TIT �,jjscxJ - G )96G r �r?Z-/ iw � C �c�s oru - fl� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> A. (-f'O1 TANK ( ) 02 OTHER ----]CONTAINER NUMBER llvk <br /> "�- YEAR MFG:Np C. YEAR INSTALLED rf�La ( ) UNKNOWN <br /> B. MANUFACTURER (IF APPR <br /> O <br /> PR(I <br /> �ATE <br /> ): R js<,�) <br /> D. CONTAINER CAPACITY: 10,V0 ✓' GALLONS i ) UNKNOWN I E. DOES THE CONTAINER STORE: f 1 01 WASTE (L-1-b2 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (vf 01 YES [ ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)= <br /> ( l 01 UNLEADED [ ) 02 REGULAR t ) 03 PREMIUM M 04 DIESEL [ ) 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: A t ) GAUGE ( 0 INCHES I ) CM f l UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) tr'S 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> IC. m O1 DOUBLE WALLED [ ] 02 SINGLE WALLED f ) 03 LINED <br /> D. (V)"01 CARBON STEEL C ) 02 STAINLESS STEEL [ ) 03 FIEERGLASS ( ) 04 POLYVINYL CHLORIDE [ ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( } 08 BRONZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br /> 0 <br />