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• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT f 1 Oft MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDVAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY ' <br /> O 2 V L 'A/ <br /> 4Z l 1 O1 FED 1 1 02 STATE W) 03 LOCAL <br /> STREET ACO ESS CITY STA' ZIP <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> r 3 �c K R o�'E ✓ <br /> STREET ADD-ESS NEAREST CROSS STREET <br /> O 4"gW Al li t h /O f e <br /> CITY N U COUNTY� ZIP <br /> M4ZlING AOCPESS , I D� -• NN 6� CZTV :Rik � STATE ZIP r ^ ` <br /> PHONE iAPEA CODE l•� TYPE OF BUSINESS lyld\\_ 7 IN 6 <br /> 01 GASOLINE STATION (�(1 02 OTHER -7— <br /> .02 p"fsEa <br /> NUMBER OF CONTAI NE PS RVR AL AREAS ONIY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> �DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> AY�1=l�P.63 212,30— <br /> T-& vJy� 7AgF Y�6 -.1 <br /> 2 <br /> COMPLETE THE FOLLOWING ON A SEPARAT FORM FOR EACH C <br /> IV DESCRIPTION <br /> A. 0\) 01 TAMC f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INST f l UNKNOWN <br /> Di Es EL �L <br /> D. CONTAINER CAPACITY: /O 000 GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (Sd,' 01 YES l 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f 1 01 UNLEADED l 1 02 REGULAR 1 ) 03 PREMIUM 04 DI f 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE f ) INCHES ( ) CM f ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 1,Y <br /> J_02 SINGLE WALLED ( 7 03 LINED <br /> 0. ( 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> —'(" ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE I 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />