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• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ----- — ---- -- <br /> f ) 01 NEW PERMIT l ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> 1 _) 02 CONDITIONAL PERMIT 1_1 06 AMENDED PERMIT_ ( ) 08 MINOR CHANGE INO SURCHARGE) <br /> I OWNER ------ - --- <br /> NAME(COPPOR ATION.I/NDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Knvo OIL f 1 O1 FED f 1 02 STATE ( 1 03 LOCAL <br /> STREET ACTRESS ' I CITY STATE ZIP <br /> 1221 E MCL-tn .� CNRTTA000C,A TiJ S'7408 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPERVISOP <br /> STREET FCC°ESS NEAREST CROSS STREET <br /> 155 E <br /> CITY COUNTY ZIP <br /> )roe <br /> So V Soo L.LLY, 453-1(P <br /> MAILING ADDRESS Cell q2�A C)1,'-Q(QG CITY STATE ZIP <br /> So@L-Lek- Cy-\ gSo73 <br /> PHONE WIAPEA CODE TYPE OF BUSINESS <br /> lg6Q 46f NO f�l 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM.EtLAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> Cceer LLLYao acv e3x" stslfGreen ) land4 Aoq -eaf 7083 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION 2 A. (li\l 01 TANK f ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): NUDE,?,o W.�o - LSL.WSTSGL YEAR MFG;10/v C. YEAR INSTALLED 1457 1 ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10)00 a GALLONS t 1 UNKNOWN E. DOES THE CONTAINER STORE: L I 01 WASTE 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l ) 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> I 1 01 UNLEADED l 1 02 REGULAR 1 1 03 PREMIUM l 1 04 DIESEL 1 1 05 WASTE OIL lXt 06 OTHERsuper LLY,leode_a_ <br /> V CONTAINER CONSTRUCTION _ <br /> A. THICKNESS OF PRIMARY CONTAINMENT: (- ( ) GAUGE f)CI INCHES f 1 CM l 1 UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 311 02 NON-VAULTED 1 ! 03 UNKNOWN <br /> C. 01 DOUBLE WALLED ( ) 02 SINGLE WALLED 1 1 03f LINED <br /> O.O. )ICI 01 CARBON STEEL f 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 OB BRONZE 1 1 09 COMPOSITE l ) 30 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 - - - - -. -- - - - PAGE 1 <br />