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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> I X O1 NEW PERMIT l 1 OS RENEWED PERMIT 1 1 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 00 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> N.ne19POGRATION.INDZVIDUAJ Of rvuOL� :c AacNCV) PUBLIC AGENCYr 0T <br /> 1 Ol FED 1 1 02-STATE f 1 03 LOCAL <br /> STREET ACSRESS CITT STAT! Zip <br /> �{spo lz� rlZfi�NOCLT �rocKr�.tt C0 ?6-&5— <br /> II FACILITY <br /> FACILITY NAME Dl ALES/POPEMENISVRERVISOR <br /> STREET ACCIESS �-% NEAREST CROSS STREET <br /> CITY// COVN/Y' �-- ZIP <br /> __ 7 VOi4Giu _ s2U 5- <br /> MAILINB ADDRESS CITY STATE ZIP <br /> _�pp_ -Ali fu�1-- TOCr To t! <br /> PHONE W•APEA COLE TYPE OF BUSINESS t <br /> 01 GASOLINE STATION SICU 02 OTHER YUXld3la!�cPRllz <br /> NUI'OER C, CONTAIHCRS --- DURAL AREAS ONLY TOWNSNIR <br /> III 24/HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NArjl L�.fS]T� NAME FIRSTI ANO PN WIAEA CODE N�O��1: NA/AMEf1AL-A/�NNAME IRSTI A11 <br /> 110-1-RRI1�"AREA C00! <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TR6C 1 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED(QY3"jr- 1_I UNKNOWN <br /> 0. C014TAI?IER CAPACITY:_ !�'�J GALLONS 1 1 UWNOWN E. DOES THE CONTAINER STORE: 1 I 01 WASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAIIIEP STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE 80XIES1: <br /> ('o 03 UNLEADED I ) 02 REGULAR 1 1 03 PREMIUM l 1 04 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> THICP.HESS OF PRIMARY CONTAINMENT: I 1 GAUGE ( 1 INCHES 1 I CM (/%0 UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN L)tIOERGROUND VAULT) q1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. 1 1 01 DOUBIE WNLLEO ty 02 SINGLE WALLED 1 1 03 LINED <br /> 0. Iw 01 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE / 1 OS CONCRETE <br /> // 1 1 06 ALUMINUM l 1 07 STEEL CLAD I 1 00 BRONZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 6 1 _1-12 LRIKNOWM ( 1 13 OTHER: <br />' HSC04-070185 PAGE 1 <br />