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APPLICATION FOR PERMIT STATE ID NUMBER <br /> TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT f ) 05 RENEWED PERMIT <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 07 MINOR CLOSEDCHANG (NO SURCHARGE)) 09 DELETE FROM FILE IND FEE) <br /> I OPINE <br /> NAME(CQRPO RATIODIVID AL OR PUBLIC AGENCY) <br /> N <br /> 1610 PUBLIC AGENCY ONLY <br /> STREET ADDRESS ( ) 01 FED f ) 02 STATE -p jh6 <br /> `f 2S L 3 LOCAL <br /> CI iY <br /> _ S <br /> Sh STATE ZIP <br /> II FACILITY Acs 9SZd <br /> FACILITY NAME ( /� <br /> C� � 1/J h (JO�(C DEALER/FOREM(�JN/SUP/ERVISOR <br /> STREET ADDRESS_ ,L�, 1�.7•r (I � QN1 p eo-c Q` <br /> 2Z <br /> E . �ar e',f NEAREST CROSS <br /> STR ET <br /> CITY ( ` O <br /> SCOUNTY i <br /> T <br /> MAILING ADDRESS ZIP <br /> p <br /> 2 i )5 M1oLr 5 CIT f <br /> STAT ZIP <br /> PHONE W/AREA CODE - - -' <br /> ," T � q _��O TYPE OF BUSINESS <br /> vw / ( ) 01 GASOLINE STATION 1 <br /> NUMBER OF CONTAINERS 02 OTHER O4, f <br /> RURAL AREAS ONLY TOWNSHIP —�•6:_'�----.___ <br /> RANGE <br /> SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY : NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> NI HTS: NA E(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> X160 ��amP <br /> COMPLETE THE FOLLOJING ON A SEPARATE FORM FOR EACH CONTAINER <br /> pA13 <br /> IV DESCRIPTION Z <br /> A. ( 01 TANK f ) 04 OTHER: <br /> CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLED f ) UNKNOWN <br /> D. CONTAINER CAPACITY: &0&6 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL I (Xf 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ): <br /> ( ) <br /> 01 UNLEADED W02 REGULAR ( ) 03 PREMIUM ( ) 04 DI 1 ) 05 WASTE OIL ( ) 06 OTHER <br /> v CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f ) INCHES ( ) CM fkn UNKNOWN <br /> B. ( l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ()<r 02 NON-VAULTED ( ) 03 UNKNOWN! <br /> C• ( )) 01 DOUBLE WALLED ( 02 SINGLE WALLED ( ) 03 LINED <br /> D• «3/.41 CARBON STEEL f ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> f ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE f ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( ) 13 OTHER: <br />. HSC04-070185 ------.— <br /> PAGE 1 <br />