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• • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK 1 <br /> 01 NEW PERMIT l ) 05 RENEWED PERMIT l 1 07 TANK CLOSED _ ( ) 09 DELETE FROM FILE (NO FEE-I_! <br /> 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT t ) 09 MINOR CHANGE (NO SURCHARGE) I! <br /> I OWNER -- <br /> NAY,w COPPOPATION INDIVIDUAL OR PUBLIC &GENCY) PUBLIC AGENCY ONLY <br /> C) �- I• <br /> 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br />' STREET AD?KESS L(or.o- �M. <br /> , - STATE ZIP �O <br /> II FACILITY <br /> FAC LITY NA-E DEALS /FOPEMEN/SUPE ISOP <br /> _Pre,C,u -o-- �p_133 <br /> + _ <br /> STREET ADOo SS NEA <br /> CITY 41 ZIP <br /> STATE 2� O <br /> nS� 5 '� CITY J <br /> MAILING ADDP <br /> r Y - 1[j _ l�tr/) `c 7 <br /> PHONE WAVE COD TVP OF BUSINESS <br /> ( 1, 01 GASOLINE STATION ( 1-02 OTHER <br /> NUMBER CF C NTAINEPS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 26 HOUR EMERGENCY CONTACT PERSON <br /> LAYS: NAME(LAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHOE W/AREA CODE <br /> - c o r Win- dao - 5 -- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CPNTAINER <br /> IV DESCRIPTION _ <br /> �A. 0 TA)(K ( ) 02 OTHER: CONTAINER NUMBER <br /> - -B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: LLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ?0EL <br /> 0 YES ( l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 01 UNLEADED ) ?,REGULAR l ) 03 PREMIUM ( ) 04 DI 1 l 05 WASTE OIL t ) 06 OTHER --_- —- <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PP.IMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( I CM ( ) UNKNOWN <br /> B. ) 01VAULTED (LOCATED IN AN UNDERGROUND VAULTNON-VAULTED l ) 03 UNKNOWN <br /> IC. (&. 3 DOUBLE WALLED ( ) 02 SINGLE WALLED 1 ) 03 LINED <br /> D. I ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> II ( 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE 1 ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> --------------------- ------- <br /> ii5C04-010185 <br /> PAGE 1 <br />