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• STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />1 NEW PERMIT 1 ) 05 RENEWED PERMIT ( ) 07'TANK CLOSED l ) 09 DELETE FROM FILE (NO FEE) <br />C'211"02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAYE(COPPORATION,INC Y_VIDUAL OR PUBLIC AGER. Y) <br />STPEET ACTRESS <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />l ) <br />01 FED 1 1 02 STATE ( ) 03 LOCAL <br />CITY j FST�ATF0160-71 <br />--7t �C l -!'Yl ra n I P. *T l 60 ( l <br />FACILITY NAME <br />A. <br />DEALER/FCPEMEN/SUPEPVISOP <br />STREET ADOMESS <br />... <br />( ) GAUGE <br />NEAREST CROSS STREET <br />(t <br />CITY <br />COUNTY `+.SJ L rA Z -L,5 -7 <br />MAILING ADDRESS <br />581 <br />CIT STATE 2I <br />U_ 1 � <br />PHONE W,ACEA CODE TYP OF BUSINESS <br />(�,-43GASOLINE <br />__.. <br />STATIOO N- ( ) 02 OTHER <br />( ) 01 <br />-•- <br />NUMBER CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP --- RANGE SECTION - <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE /AREA CODE NI NTS: NAME(LAST NAME FIRST AND PHONE W/APEA CODE <br />CeL,r I 010 -t -I a,LD b0- <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />TV DFSCP.TPTTON <br />c`•r I A <br />01 TANK ( ) 02 OTHER: <br />B. MANUFACTURER (IF APPROPRIATE): <br />CONTAINER NUMBER <br />YEAR MFG: I C. YEAR INSTALLEQ.,.11fb& 1 l UNKNOWN <br />0. CONTAINER CAPACITY: �- GALLONS t ) UNKNOWN JE. DOES THE CONTAINER STORE: ( 1 01 WASTE ( 02 PRODUCT <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( I,DT YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( 1 01 UNLEADED ( ) 02 REGULAR ) 03 PREMIUM ( ) 04 DItSfL ( ) 05 WASTE OIL k1 06 OTHER -, <br />V CONTAINER CONSTRUCTION <br />H5C04-0 0185 <br />PAGE 1 <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: C).240 <br />( ) GAUGE <br />(<) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) ( V, 02 <br />NON -VAULTED ( <br />) 03 UNKNOWN <br />IC. <br />( ) 01 <br />DOUBLE WILLED <br />()(� 02 SINGLE WALLED l <br />) 03 LINED <br />— <br />01 <br />CARBON STEEL <br />( ) 02 STAINLESS STEEL ( <br />1 03 FIBERGLASS <br />( ) 04 <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) <br />06 ALUMINUM <br />l ) 07 STEEL CLAD t ) 08 <br />BRONZE 1 <br />) 09 COMPOSITE <br />( ) 10 NON-METALLIC <br />( ) 12 <br />UNKNOWN ( ) <br />13 OTHER: <br />H5C04-0 0185 <br />PAGE 1 <br />