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• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> X1O1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 ) 08 MINOR CHANGE (N0 SURCHARGE) <br /> I OWNER <br /> NAr��.}fO PORATION. NOIVI�WAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> j) (� a ��L ( ) 01 FED ( 1 02 STATE f ) 03 LOCAL <br /> STP fi0 i:> F C CITY ST�Ia. LIP� <br /> II FACILITY <br /> FA TY NAM r� / OE4LER/FORT Mf N/SUPERVISOR <br /> G <br /> STREET ADDIESS NEAPS T DROSS STREET <br /> CITY '' II COUNT ZIP <br /> tcsv- �"^ (JI -�03 <br /> M424{MQ64 � CITY ST j,E , ZIP <br /> P MONL Wi APEA CODE TYPE OF BUSINESS <br /> OI - .C16 7�p� l ) O1 GASOLINE STATION ('l�02 OTHER <br /> NUMBER 01 CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> ID C'Is3a��A NAME F RIT) AND 9 d6� CODE <br /> NI�a��/Etj T EY PIRST) A;-PHONE W�IYROE 27E <br /> a'l. COMPLETE THE FOLLOWING ON A SEPARATE FORM T/FFOJW_RC•8-ET'IAACH wrCOOONTA_�/IINER 4 <br /> IV DESCRIPTION <br /> A. W"'01 TANK f 1 02 OTHER: CONTAINER NUMBER2, =tr- <br /> 5. <br /> MAM)FACTURER (IF APPROPRIATE): p�, iW YEAR MFG: 5 C. YEAR INSTALLED l 1 UNKNOWN <br /> N <br /> D. CONTAINER CAPACITY: /G� GALLONS�(WNOWE. DOES THE CONTAINER STORE: ( 1 01 WASTE (�2 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE.02t 1 1 01 YES f ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED 1 ) 02 REGULAR ( ) 03 PREMIUM (VO4 DIESEL l 1 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: � II f ) �GAUGE 01/INCHES ( ) CM f 1 UNKNOWN <br /> B. 1 1 01 VAULTED ILOCATED IN AN UNDERGROUND VAULT) ("2 NON-VAULTED ( ) 03 UNKNOWN <br /> C. IV) O1 DOUBLE WALLED f ) 02 SINGLE WALLED 1 ) 03 LINED <br /> D. (&l/01 CARBON STEEL ( 1 02 STAINLESS STEEL X 03 FIBERGLASS ( ) 04 POLTVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM ( ) 07 STEEL CLAD [ 1 08 BRONZE 1 > 09 COMPOSITE ( ) 10 NON-METALLIC <br /> t ) 12 UNKNOWN ( ) 13 OTHER: <br /> NSC04-070185 PAGE 1 <br />