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r <br />• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Flll;-21-11- <br /> I <br /> EIN f""IT t `1 95 REt*mto`PERMIT 1 1 07 TANK CLOSED [ 1 09 DELETC FROM FILE tNO FEE) <br /> ONDITIONAL PERMIT 1 1 06 AMENDED PERMIT t 1 04 MINOR CHANGE (NO SURCHARGE) <br /> .� OWNER �`j � q � 1� �Z- / ' 1 ,� f S /✓ le 4I 9 <br /> NAMEICOPPORATION,tHOIVIDUAL OR PUBLIC AOENCYI PUBLIC AGENCY ONLY <br /> 1 01 FED 1 1 02 STATE 11 03 LOCAL <br /> STREET AOOR[SS CITY STT ZIP <br /> II FACILITY <br /> FACILITY NAME DEALEROPEMEWSUPEA IR <br /> STREET ADDIESS NEAREST CROSS STREET <br /> CITY > COUNTY ZIP <br /> 1 MAILING ADDPE CITY STATE LIP i <br /> PHONE W AVER CODE TYPE OR BUSINESS Z/. _ <br /> 1 01 GASOLINE STATION L>q 02 OTHER - <br /> NVP'SER CF CONTAINERS /�J� PUPAL AREAS ONLY : .MSNIA PANGS SECTION. <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OAY : N MECLAST NAME FIPSTI AND PHONE W/AREA CODE NIFTSS NAMEALAST NAME FIRSTI AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. i k 01 TAt?K 1 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER LIF APPROPRIATE): /? YEAR MFG /7 C, YEAR INSTALLED t UNKNOWN <br /> D. CONTAINER CAPACITY GALLONS [ ! UNKNOWtI JE. DOES THE CONTAINER STORE: p(1 01 HASTE i 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? IXI 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOXtESI' <br /> t 1 01 UNLEADED 1 1 02 REGULAR [ 1 03 PREMIUM ( 1 04 DIESEL K) OS WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT' 1 1 GAUGE 1 1 INCHES 1 I CM lk1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UIIOERGROUII) VAULT) '1 1 02 NON-VAULTEO 1ly, 03 UNKNOWN <br /> 1C. ( 1 01 DOUBLE WILLED 1 1 02 SVIGLE WALLED 1 103 LINED <br /> fD. f 1 01 CARBON STEEL I 1 OZ STAINLESS STEEL 1 103 FIBERGLASS i 1 04 POLYVINYL CHLORIDE l �KRETE <br /> --- [ 1 06 ALUMINUM I 1 07 STEEL CLAD ( 1 08 BRONZE t 1 09 COMPOSITE { 1 10 NON-MET ���' <br /> 11 12 UNKNOWN I 1 13 OTHER , <br /> n,C04-Oi�185 I , PAGE 1 <br /> 0111-1 <br /> ENVIROMENTAL HEALTH _ <br /> F ERMIT/SERVICES <br />