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SSTATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />qj,rNEW PERMIT ( 1 05 RENEWED PERMIT ,( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />( <br />012 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAMElCOPPOR­AT I0N.I CIVIDUAI OR PUBLIC A �N-C�Y�)j ,, <br />`-----_` - � —LD- ��--+-c� _ to i]��. -' s <br />!STREET ACDRESS <br />II FAC_.ILITY <br />PUBLIC AGENCY ONLY <br />( ) 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br />CITY STATE ZIP <br />I fl -r, � , ( 0 < I CS1 (?-6 6 '7 <br />< <br />FACItITY NAME � <br />DEALER/f OPEMEN/SUPERVISOR <br />i'STPEET ACCESS y <br />NEAREST CROSS STREET <br />CITY <br />COUTY <br />ZIP <br />�3 <br />'MAILING A ESS <br />c LJ 1 <br />CIT <br />STATE <br />c4 1 <br />ZIP' <br />i--� <br />�PMONE W,ACEA ODE i -7 <br />ii -r 14 I <br />TYPE <br />I�j �G <br />OF BUSINESS <br />01 GASOLINE STATION ( ) <br />02 OTHER <br />_ <br />NW)BEV CF CONTA1NEPS - <br />- - PUPAL AREAS <br />ONIY ; TOWNSHIP ---- <br />RANGESECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />10AYS: NAME(LAST NAME FIRST) AND PMO E W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND HONE W/AREA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (�,A Q01 TANK ( 1 02 OTHER: <br />MANUFACTURER (IF APPROPRIATE): <br />CONTAINER NUMBER L_ <br />YEAR MFG: 1 C. YEAR INSTALLEDIf4v ( ) UNKNOWN <br />D. CONTAINER CAPACITY: = j _- GALLONS ( ) UNKNOWN JE. DOES <br />'THE <br />�CONTAINER STORE: <br />F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? p(y01 YES ( 1 02 NO <br />-1 -) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM_ ( 1 04 DIESEL (X) 2> WASTE OIL <br />V CONTAINER CONSTRUCTION <br />L WASTE ( ) 02 PRODUCT <br />IF YES CHECK APPROPRIATE BOXIEST: <br />l ) 06 OTHER <br />A. THICKNESS OF PRIMARY CONTAINMENT: q ( ) GAUGE C<l INCHES ( 1 CM ( ) UNKNOWN <br />B. ! 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (K),02 NON -VAULTED ( ) 03 UNKNOWN <br />IC. t ) 01 DOUBLE WALLED 06 02 SINGLE WALLED ( ) 03 LINED <br />D. (,>�01 CARBON STEEL �02 STAINLESS STEEL ( 1 03 FI6ERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />06 ALUMINUM l ) 07 STEEL CLAD ( ) 08 BR014ZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br />(Z/) 12 UNKNOWN ( ) 13 OTHER: <br />H3C04-0 0185 PAGE 1 <br />