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TATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> LAI EW PERMIT ( 1 05 RENEWED PERMIT l 1 07 TANK CLOSED <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( PERMIT l ) 06 AMENDED PERMIT ( ) 09 MINOR CHANGE E (NO_`'URCHARGE) <br /> I OWNER <br /> PUBLIC AGENCY ONLY <br /> NAME(CORPORATION,INDIVIOUAL OR PUBLIC AGENCY) ( ) 01 FED ( ) 02 STATE { 03 LOCAL <br /> -- CITY J STATE IIP <br /> STPEE ., E -Sc 5+c C 95�aa� <br /> 0Ay,_ <br /> Jr- <br /> II FACILITY <br /> DEALER/FOREMEN/SUPERVISOR <br /> FACILITY NAME <br /> ID aAlf-- NEAREST CROSSSTREET <br /> STREET ADO"ESS ?O <br /> 5 <br /> Z COUNT_Y y 8 <br /> CITY 533 Lo <br /> /^� SFIIL)J� Lei - <br /> rn t — STATE_ ZIP <br /> CITY /�I/x'/71 <br /> MAIL NG ADDRESS <br /> TYPE OF BUSINESS <br /> PHON� EAcoDE ( 1 <br /> 01 GASOLINE STATION (X) 02 OTHER <br /> SECTION <br /> NUMBER CF CONTAINERS <br /> PUPAL AREAS ONLY TOWNSHIP RANGE <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME( LAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LPST NAME FIRST) AND PHONE W 1RZ CODE <br /> k �---- <br /> s— <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINE <br /> IV DESCRIPTION <br /> CONTAINER NUMBER <br /> A. (X) O1 TANK ( 1 02 OTHER: 0. <br /> YEAR MFG: C. YEAR INSTALLED �� ( 1 UNKNOWN <br /> B. MANUFACTURER (IF APPROPRIATE)• <br /> D. CONTAINER CAPACITY: I ODO GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 O1 WASTE ( 1 02 PRODUCT <br /> F. DOES OTHE CONTAINER STORE <br /> ERMOTOR VEHICLE FUEL OR PREMIUM <br /> T1 OIL <br /> 04 0IESEL 0( )YES <br /> 05 ( ) 02 NO <br /> (I1 YES <br /> OCHECK APPROPRIATE BOX(ES): <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (A) UNKNOWN <br /> B. ( 1 O1 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (J(1 03 UNKNOWN <br /> C. 1 O1 DOUBLE WALLED ()(I 02 SINGLE WALLED ( 1 03 LINED <br /> D. i 01 CARBON STEEL L ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 OS CONCRETE <br /> l 1 06 ALUMINUM l 1 07 STEEL CLAD ( 1 OB BRONZE ' ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 12 UNKNOWN ( 1 13 OTHER: <br /> _ PAGE 1 <br /> HSC04-070185 <br /> as , 46 <br />