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1 -j--s' �_o <br /> STATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK 1 <br /> 1 1 01 NEW PERMIT l 1 05 RENEWED PERMITI TA O<� ( ) 09 DELETE FROM FILE (NO FEE) I <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 ) 0 MINOR CHANGE INO SURCHARGE) <br /> I OWNER <br /> NAW)COP PORATION.INC=VIDUAL OR PUOLIC AGENCY) , PUBLIC AGENCY ONLY <br /> 01 FED 1 1 02 STATE 1 03 LOCAL <br /> F,-TP!-ET AC RCS,SF D woo ml gsao6 <br /> II FACILITY <br /> FACILITY OC AIC�R,/:0=[nCN�SVPCP <br /> oVISOP AA <br /> SroWm <br /> STREET ACC'IESS ` NEAREST TCCROSS <br /> S f/•T pE►�P�� 7J"v_ <br /> 5600 's. {}1 f} GLch <br /> CITY COUNTY Q� Jf SIP <br /> hoc"A) <SF9 v qS ao6 <br /> CITY_ ♦ TTA�TC ZIP <br /> MAILING ADDPCSS A CJJ 1��/1 L^TAT <br /> o R zo <br /> ,MON! W'APCACOpE� TY P[ OF DUSIN!SS v �y�Q <br /> 77 l 1 O1 GASOLINE STATION I^1 02 OTHER <br /> NU[6ER CE CON TAINCPS <br /> RURAL AI AREAS ONLY TOWNSHIP PANGS SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAr,E(LAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: HAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> 1 Ta4fr;ayz 10 9�� 0313 ;7L _o�¢aT.'ass a2o5-�8� 0373 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> 4 Ay� � 1 <br /> A. (XI 01 TANIK 1 1 02 OTHER: -�1 CONTAINER NUMBER aAACVDW4 <br /> B. MANUFACTURER (IF APPROPRIATE): vA.*VOU D IVA) YEAR MFG: C. YEAR INSTALLED tkl UNKNOWRI <br /> 0. CONTAINER CAPACITY: GSO GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 Ol HASTE l 1 02 PRODUCT — <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 O1 YES Ik{ 02 NO IF YES CHECK APPROPRIATE BOKIESI: <br /> 1 1 O1 UNLEADED 1 1 02 REGULAR f 1 03 PREMIUM 1x1 04 DIESEL l 1 05 HASTE OIL 1 1 06 OTHER <br /> •V CONTAINER CONSTRUCTION <br /> A. iH ICY.NESS OF PP.IMART CONTAINMENT: ( 1 GAUGE 1 1 INCHES 1 1 CH Ikl UTA(NOHN <br /> B. 1 101 VAULTED (LOCATED IN AN UNDERGROUND VAULTI 1 1 02 NON-VAULTED 1 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WILLED f 1 02 SINGLE WALLED 1 1 03 LINED (1VL1AfOWA) <br /> D. 1 1 01 CARBON STEEL l 1 02 STAINLESS STEEL 1 1 01 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> ( ) 06 ALUMINUM l 1 07 STEEL CLAD l ) 06 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> �x X, 12 UNKNOWN l ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />