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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> bl NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 04 DELETE' FROM FILE (NO FEE) <br /> 102 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE INO SURCHARGE) <br /> I O14NER <br /> NpYE4C IN AL OR CUBLIC AGENCY) PUBLIC AGENCY ONLY r— <br /> ( 1 01 FED ( 1 02 STATE { 103 LOCAL <br /> S7cEE71�AC1fR�y557`�q, CITY STATyEQ Z P36L <br /> _„ <br /> II FACILITY <br /> 51 <br /> FACILITY NAME i � DET/FO[EMENISUPERVISOR <br /> r DD - <br /> � <br /> STREET FESS NEAREST CROSS ET- Ijll'J'li L <br /> CITY CO NTY ZIP. 5.3 -.Z)4(moi. 1 J <br /> rt — <br /> 4jEr` MAILING ADDPESS CITY STATE ZIP <br /> PHONE W,Ar • CODE TYPE OF 15USIN°SS <br /> S ( bl OLINE STATION { 1 07 OTHER <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY TOW`iStiIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME)LAST NAME FIPST) AND PHONE W/ PEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> w:•B• <br />•=-:�: A. 1 01 TANK { ) 02 OTHER CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEI: YEAR MFG= C. YEAR INSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: _ iV GALLONS ( 1 UNKNOWN JE. DOES THE CONTAINER STORE- ( 1 01 WASTE (x) 02 PRODUCT _ <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL " YES 1 1 02 NO IF YES CHECK APPROPRIATE BO)((ESI: <br /> f 1 01 UNLEADED { 1 02 REGULAR 66i 03 PREMIUM ( 1 04 DIE EL ( 1 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT' ! 1 GAUGE 1 1 INCHES ! 1 CM ( I UNKNOWN <br /> B. ( 1 01 VAULTED {LOCATED IN AN UNDERGROUND VAULT) 2 NON-VAULTED t 1 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WALLED I/*c_5 NGLE WALLED [ 1 03 LINED <br /> D. l 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL FIEERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM I 1 07 STEEL CLAD [ 1 BR011ZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> { 1 12 Llt1KN0WN { 1 13 OTHER <br /> H5C04-0701$5 PAGE 1 <br /> 0 <br />