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_! / • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> XXI 01 NEW PERMIT ( 1 OS RENEWED PERMIT 1 1 07 TANK CLOSED 1 1 09 OELETV FROM FILE (NO FEE) <br /> 40or02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAM!(CO PPORATION.INDIVIDUAL OR PUSLSC AGENCY) PUBLIC AGENCY ONLY <br /> K•�.� p p �� 1 1 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> STP{C1 ACI)9lSS ��� �/ v. M Al�V CITY�� G• STAT ZIP ��� 6 <br /> II FACILITY <br /> FACILITY NAMt DEALER/FOREMEN/SUPERVISOP <br /> S:PCCT tOC�C 5- � ' ��y NEAREST CROSS TPEET <br /> CITY - L Z COUNTY -5 ZIP r-3 - <br /> C <br /> MAILING ♦f DRESS 1 R) G CITY ^ ^-� C STATE LIP f. <br /> PHONE N•AAvP CODE_ - ♦ TYPE OF /USIN!SS ' V <br /> 9 1 _ G 1 1 01 GASOLINE STATION 1 1 02 OTHER <br /> NUMDCR CP CONTAINERS PUPAL AREAS ONLY TONNSHIP _ RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAY.EILAST NAME FIRST) AND PHONE WAVE CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> o�N�+ rr JFK i 2,e5—�3q-3 l l� o L_No 5kl', ;T <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (x 01 TAMC f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): uN YEAR MFG: C. YEAR INSTALLED <) UNKNOWN <br /> 0. CONTAINER CAPACITY: /QQ d GALLONS 1 1 UNKNOWN) E. DOES THE CONTAINER STORE: 1 1 01 WASTE 1 ) 02 PRODUCT <br /> F. CLOES THE CONTAINER E MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BO%IESI' <br /> 1 ) 0 UNLEADED l 1 02 REGULAR 1 1 03 PREMIUM C 1 04 DIESEL ( 1 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TH ICY•NESS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 1 INCHES 1 I CM I UNKNOWN <br /> B. 1 1 01 VAUL7EO (LOCATED IH AN UNDERGROUND VAULT) 1_1 02 NDN-VAULTED ( 1 01 UNKNOWN <br /> IC. t 1 01 DOUBLE WALLED 1 1 2 SINGLE WALLED ( ) 01 LINED <br /> 0. CARBON STEEL 1 1 0? STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE j <br /> ( 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 08 BRONZE I ) 09 COMPOSITE 1 1 10 NON-METALLIC <br /> l ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />