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• . STATE IO NUMBER <br /> ... <br /> APP�.ICAT<ION FOR PERNIT, TO OPERATE -UNDERGROUW STD G .;SANK <br /> 1 1 Ol t+lEll PEfFItIT x%1 t 4 Of RENEIIEQ IERMIT,> i I L4lT TAlAI;,I*1►q�EO t 1,;09 DELETE• fROM FILE iN0 FEE 1 <br /> 1 1 Of COMITIONAL PERMIT 'I 1 O6 AMEW10 PERMIT t 1 64 tltt KHAN (W SURCHARGE)_' <br /> I OWNER <br /> NAMI(CORPORATION,INOIVIOUAI OR PUDL2 AGENCY) PUBLIC AGENCY ONLY <br /> 1 1 01 FEO 1 1 02 STATE 1 03„LOCAL <br /> lTRl;f AOdRtii. �r ".'. 3 �. _ � ITY STAT[ 2IP.:: <br /> nr <br /> 'a <br /> ' II FACILITY <br /> FACILITY NAME � / D[ALIR/fOP[M!N/iVPlRVISOR <br /> STREET A000ESS NEAREST CROSS STREET <br /> CITY y�Ay� COUNTY ZIP <br /> MAIIINO'AOOPESS - Fry <br /> STAT! !IP l <br /> PHONE U-14"114 COOS TYPEil <br /> oUSINEii <br /> 1GASOLINE STATION ( 1 02 OTHER <br /> Hurst* CP CONT of RURAL AREAS ONLY TOWNSHIP RANGE SECTION. <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> EA"91LAST NAM! FIFTY) AND PHONE W/AREA COO! <br /> Flo” <br /> TSt HAMEILAST NAME FIRST.) AND PHONE W/AIXA:COOE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> f <br /> A. t 01 TAMC ( 1 02 OTHERS CONTAINER NUMBER <br /> - B. MANUFACTURER-fIf APPROPRIATE I: �f//t/) YEAR MFG: �i� C. YEAR INSTALLED � ( _1 UNKNOWN <br /> 0. CONTAINER CAPACITT:rC/ �jl/ GALLONS t 1 UNKNOWN E. GOES THE CONTAINER STORE: ( 1 O1 WASTE l!/1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHI FUEL OR WASTE OIL ? ( 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 01 UINLEADED ( 1 02 REGULAR (! o3 PREMIUM t 1 04 DIESEL l 1 OS WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: I 1 GAUGE ( 1 INCHES ( 1 CM 1 UNKNOWN <br /> S. ( 1 01 VAULTED (LOCATED IN AN UNOERGROU110 VAULT) •1' 02 NON-VAULTED 1 1 03 UNKNOWN <br /> C. ( 'S �OLE WALLED l 1 02 SINGLE MALLEO ( 1 03 LINEO <br /> I0. 1 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> ( 1 06 ALUMINUM 1 1 07 STEEL CLAO ( 1 OD BROIIZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ' -1 -1 12 UNKNOWtI ( ) 13 OTHER: _--- _---- _ -- -_— -_- <br /> HSC04-070185 PAGE 1 <br /> � i - <br />