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STATE IO NUMBER <br /> ((( APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ()4101 NEW PERMIT -- I ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 OELETE' FROM FILE (NO FEE) <br /> ( 1 02 COtIDITIONAL PERMIT _t ) 06 AMENDED PERMIT ( ) 08-MINOR CHANGE (NO SURCHARGE) —`- <br /> I OWNER <br /> NAY.!(COPPCRATION.INCIVIOUAI OR PUBLIC AGENCY) PUO LIC AGENCY ONLY <br /> 01 FED ( ) 02 STATE ( ! 03 LOCAL <br /> ST0!!T ACTRESS CITY STATS ZIP <br /> co vv <br /> II FACILITY <br /> FACILITY NAY DEALER/FCPEMEN/SUPERVISOP <br /> —�C� c�t" G�C:� � '�'N L c•C� C ) �� _ �!t-���. C� � �l.(..GC fr(�� — <br /> STPEET ACCESS NEAREST CROSS STREET^ <br /> C.TY COUNTY <br /> ZIP <br /> •f,,•'. MAILING AODPESS CITY STATE ZIP <br /> J <br /> PHONE W%ACEA COOE TYPE CF BUSINESS <br /> c-' _ z' -5 5 -� -71-7O ( ) 01 GASOLINE STATION AY 02 OTHER <br /> NUMBER CF CONTA LIVE�r-R S///JJ RURAL AREAS ONLY : TOWNSHIP PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> 0 YS: <br /> //NAM,E(LAST NAME FIPST) ANO PHH+ONE W/APEA COOS NIGHTS: NAME(LAST NAME /FIRST) AND PHONE WJAREA COOE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> •': < A. 01 TANK ( ) 02 OTHER CONTAINER NUMBER ` <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: TC. YEAR INSTALLED ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: tri[; GALLONS ( ) UNKNOWN E. GOES THE CONTAINER STORE: ( 1 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL '>' 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR 03 PREMIUM ( 1 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> [A. THICY•NESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( )-CM UNKNOWN <br /> B. t ) 01 VAULTED (LOCATED IN AN UNOERGROUNO VAULT) ' >�02 NON-VAULTED ( ) 03 UNKNOWN <br /> 1C. ( ) 01 DOUBLE WILLED (>A2 SINGLE WALLED l 1 03 LINED __ _-- <br /> 0. 1 ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BROt)ZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> I ( ) 12 UNKNOWN ( i 13 OTHER: _ <br /> --------- ---- _—. - <br /> HSC04-070185 PAGE <br />