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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO <br /> FEE)� <br /> l_7 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 06 MINN CHANGE (NO SURCHARGE) <br /> I GONER <br /> Nlnf(COPPORATIOH,INOIV L7.11 oR ►Up(iC AO[NCY�,1 PUBLIC AGENCY ONLY <br /> j 1 j p� ( ) 01 FED ( ) 02 STATE 1 ) 03 LOCAL <br /> iSTREET ADDRESS CITY iTAT[ ISP <br /> Ido Sue-o Sfre�t 1 haeiZ , x. <br /> II FACILITY <br /> (FACILITY NAME DEALER/FOREMAN/SVPERVISO■ <br /> ��— <br /> STf CCT ADDRESS NEAREST CROSS STREET <br /> �C a' <br /> COUNTY ZIP <br /> MAI UNG ADDRCSS CITY <br /> STATE ZIP <br /> i <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> I (J() 01 GASOLINE STATION ( ) 02 OTHER <br /> IMUMp[0 0/ CONTAIN-PS RIR AL AREAS ONLY TOWNSHIP RANG! SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> ,�,S: NAME(LAST NAME PIRST) AND PHONE 4/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA COD! 1 <br /> hLl_r nh�r �(1yCin I <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. Q') 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG N1 C. YEAR INSTALLED (X UNKNOWN <br /> j0. CONTAINER CAPACITY: '4, 000GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (o 02 PRODUCT <br /> F. OOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ()el O1 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( l <br /> 01 UNLEADED 1 ) 02 REGULAR (Al 03 PREMIUM f ) 04 DIESEL ( ) 05 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f 1 GAUGE ( ! INCHES t ) CM )1,/) UNKNOWN <br /> e. l 101 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 WJH-VAULTED 1 ) 03 UNKNOWN <br /> C. 1 Y 01 DOUBLE WALLED ( 1 02 SINGLE MALLEO l ) 03 LINED <br /> 0. Ix) O1 CARSON STEEL 1 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS t 1 04 POLYVINYL CHLORIDE ( ) OS CONCRETE <br /> ( ) 06 ALUMINUM 1 1 07 STEEL CLAD ( 1 OB BRONZE l ) 09 COMPOSITE l 1 10 NON-METALLIC <br /> ! 1 12 '14KNO.N 1 ) 13 OTHER: <br /> PAGE 1 <br /> 5004-07018, <br />