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'} • � STATE IO NUMBER <br /> rL APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f,{1 <br /> 01 NEW PERMIT l 1 05 RENEWED PERMIT l 1 07 TANK CLOSED ( ) 09 DELETE' FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( 1 OB MINOR CHANGE IND SURCHARGE) <br /> I OWNER <br /> NAMEICOPPORATION.IMOIVIOUAL O UeLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 01 FED 1 1 02 STATE l 1 03 LOCAL- <br /> fTeCET ACTRESS /�� �� � C T ,Y STATE ZI ; <br /> SJ s / " / �J1 <br /> II FACILITY _ <br /> FACILITY HAM ) DEALER/FOPCMCN�SUPFPVIS OP A <br /> !//v/ — <br /> STPEET AOC'CSS NEAPOST CR O,$_S PFFT <br /> CITY tk ec - COUNTYS pro �L� P s-3 3 6 <br /> _ <br /> MAILING ACOPFSS_/ � �Y O� <br /> 2z u-7 <br /> CITO <br /> Y /( _ STATE ZI'7 <br /> PMONC WAPEA C ��f`fit/ TYPE OF eUSIN£SS <br /> I ) 01 GASOLINE STATION l 1 02 OTHER <br /> Nureu CF-'� TAINCPS PVPAL APEAS ONLY TOW MS HIP PANGC SlCTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEILAST NAME PIPSTI AND PMONE W/APEA CODE NIGHTS: NAMCI lAST NAME FIRST I-ANO_PHONE W/ARCA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION _.._ <br /> A. 1 ) 01 TANK l 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG- C. YEAR INSTALLED 1 UNKNOWN <br /> D. CONTAINER CAPACITY' GALLONS ( 1 UNKN04Ri E. GOES THE CONTAINER STORE: 1 1 01 WASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BO%IES1: <br /> 1 1 01 UNLEADED ( 1 02 REGULAR N ) 03 PREMIUM 1 1 04 DIESEL 3?<)) 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> [A,. THICKNESS OF PRIMARY CONTAINMENT: l 1 GAUGE 1 1 INCHES 1 ) CM I UNKNOWN <br /> B. ( 1 01 VAULTER (LOCATED IH Atl UNDERGROUND VAULTI l 1 02 NON-VAULTED I 1 03 UNKNOWN <br /> iC. 1 11 01 DOUBLE WILLED Ix 02 SINGLE WALLED 1 1 03 LINED <br /> D. CARBON STEEL 1 2 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> I 106 ALUMINUM 1 1 07 STEEL CLAD 1 1 OB BRONZE ( 109 COMPOSITE ( 1 10 NON-METALLIC <br /> L. . 1 1. 12 UNKNOWN ( 1 13 OTHER_----_ <br /> PAGE 1 <br /> HSC04-070185 <br /> h <br />