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TSI <br /> R STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEN PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> L_ 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 1 06 MINOR CHANGE (NO SURCHARGEI <br /> I OWNER <br /> NAM[(COPPORAT ON.INDIVIDUAL 00 PUBLIC AG T) PUBLIC AGENCY ONLY <br /> -711E p B �� •N. �VC _L ( 1 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> Sri P[[T ACTRESS /+�I`U T CITY STATE LII <br /> � _ I 2 tf/,u 9,00(f� <br /> II FACILITY <br /> FACILITY MAKE DEALIR/ro <br /> Te,p p.,q tIre_tA F_ <br /> STREET ADDRESS NEAREST CROIX STREET <br /> carrSel✓ J coONTr S•. IPC;,_ � <br /> fHAIlINO AOOP[S6 �l�fG�j _ I� - _ CITY STATf. ZIP��� <br /> PM W/AP[A C <br /> � N 6 %,[/4/•'/T[`r P[ O✓FGASOLINE <br /> 6 LINE <br /> NESS <br /> () b ( 1 O1 GASOLINE STATION ( 1 022 OTHER N <br /> NVCB[R Cr CONTAIN[RS / RVRAI AREAS ONIr : TOWNSHIP •ANGF SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAr.ENIAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMC(LAST NAME FIRST) ANO PHONE W/APEA COOE <br /> F - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />.' A. 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER IIF APPROPRIATEI: YEAR MFG: C. YEAR INSTALLED 6 1 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS 1 1 UNCNO101 E. DOES THE CONTAINER STORE: I 1 01 WASTE I ) 02 PRODUCT <br /> F. DOES THE CONTAI14ER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES l ) 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> ( 1 01 UNLEADED ( 1 02 REGULAR 1 1 03 PREMIUM 1 1 04 DIESEL f OS WASTE OIL 1 1 06 OTHER <br /> .V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( i GAUGE ( I INCHES ( I CM 1 1 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> C. x 01 DOUBLE WALLED ( 1 02 SINGLE WALLED l 1 03 LINED <br /> D. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 1 06 ALUMINUM1 1 07 STEEL CLAD 1 ) 06 ORONZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> V46 <br /> 1 1 12 UNKNOWN `/' 613 OTHER: <br /> - HSC04-0:0185 PAGE 1 <br /> Y j <br />