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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (XI 01 NEW PERMIT 1 ) OS RENEWED PERMIT t 1 07 TAW CLOSED 1 7 09 DELETE FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT ( ) 06 AHEtJ^ED PERMIT 1 1 OD MINOR CHANGE (NO SURCHARGE) <br /> lllI 0PINE R <br /> 'N AME(CORPORATIONDIVIDUAI OR RUBLIC AOINCY) PUBLIC AGENCY ONLY <br /> -� 1 + Z(�C f ) O1 FEO ( ) 02 STATE ( 1 03 LOCAL <br /> 'StvCFT DRESS CITY STAT! ZIP <br /> AD <br /> � _tic SwenLh S�ree� �hoes�� � �z sS' (L <br /> II FACILITY <br /> FACILITY NAME DIALER/FOREMAN/SUPERVISOR <br /> �STPECT ADDRESS NEAREST CROSS STREET <br /> CITY COUNTY IIP <br /> MAILING ADDRESS CITY STATE ZIP <br /> (PHONE W/AREA CODE TY7 OF BUSINESS <br /> Y- 1�1 0 <br /> 1 GASOLINE STATION l 1 02 OTHER <br /> NUNp1P OF CONTAINERS PYRAL AREAS ONLY TOWNSHIP RANO[ SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> 'C'N S: NAME4LAST NAME FIRST),AND PNONf W/ARRA CODE NIGHTS: NAMEILAST NAME FIRST) AND PHONE W/AREA CODE <br /> !__ �c'�uf��acher� Sl�trh�Fl CGS 33(-aSyo <br /> LOMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1x1 01 TANK ( ) 04 OTHER: CONTAINER NUMBER <br /> . MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1 X1 UNKNOWN <br /> t- <br /> 10. CKWTAINER CAPACITY: �C, L G(, GALLONS ( ) UNKNOWN E. DOES THE CONTATHER STORE: ( 1 01 WASTE ( A 02 PRODUCT <br /> �F, DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 7 (A 01 YES 1 ) 02 NO IF YES CHECK APPROPRIATE PDX(ES): <br /> OC) 01 UNLEADED ( ) 02 REGULAR 1 ) 03 PREMIUM t ) 04 DIESEL ( I OS WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> !A. THICKNESS OF PRIMARY CONTAINMENT: [ 1 GAUGE ( 1 INCHES ( ) CM Y I UNKNOWN <br /> 01 VAULTED (LOCATED IH AN UC)ERGROUID VAULT) lX) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 1 01 DOUBLE WALLED f ) 02 SINGLE WALLED 1 1 03 LINED <br /> 0, Q6 01 LARBON STEEL 1 1 02 STAINLESS STEEL 1 ) 03 FIBERGLASS t ) 04 POLYVINTL CHLORIDE 1 ) OS CONCRETE <br /> f ) 06 ALLRIIN M 1 1 07 STEEL CLAD ( ) OB BRONZE ( ) 09 COMPOSITE l 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN 1 ) 13 OTHER: <br /> PAGE 1 <br /> 45CD4-070195 <br />