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i <br /> STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1`Jl O1 NEN PERMIT 1 1 OS RENEWED PERMIT 1 1 07 TANK CLOSED 1 1 -09—DELETE—FROM FILE (NO FEE) <br /> 1 _1 02-CONDITIONAL PERMIT (-1 06 AMENDED PERMIT t 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMLI COPPORATION.INDIVIDUAI OR ►UD,}IC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED 1 1 02 STATE 1 1 03 LOCAL <br /> STREET A019[SS CITY STATE IIP <br /> ��9D__IG�I�-c�►.� _ _ �To�o�! C� QSZos <br /> II FACILITY <br /> FACILITY AMC OEAtER/FOP[MEN/SU►EPVISOP <br /> STREET ADO+ESS NEAREST CROSS STREET <br /> CITY p <br /> _ COUNTY <br /> MAIL(IINNGGAAyO�DR[ss CITY STATE II/D�. _ <br /> ►H.ONE W.A.E. COOP ITYPE CF DUSINESS <br /> _126 01 GASOLINE STATION PC) 02 OTHER <br /> NVI'D[R CF CONTAIN--- RV►Al AREAS ONLY <br /> TOWNSNI► — RANGE SECTION-- _ <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: N.rCl tt- T NAME FIPSTI AND ►NONE W/AREA CODE � NI,GH�TSS: NAltItAIT NAME FIRSTI ANO RHONE 11APEA CODE <br /> . T — - ` $$� I f1,tL�ilt7R�i2[[Ib GX2(JIGI� � 5zs?y2 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV ✓JDESCRIPTION <br /> A. 1 01 TALK 1 1 02 OTHER: CONTAINER HUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED Q 1 1 UNKNOWN <br /> 0. CONTAINER CAPACITY:- GALLONS l 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1.01 WASTE 1e1 02 PRODUCT_ —- <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> I 1 01 ONLEADED 02 REGULAR ( 1 03 PREMIUM 1 1 04 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br />'tA THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 1 INCHES ( 1 CM /_ UNKNOWN <br /> II{{B. 1 1 01 VAULTED ILOCATEO IN AN UUOERGROU01 VAULTI (X) 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> IC. 1 I 01 DOUBLE WILLED (VI 02 SINGLE WALLED ( 1 03 LINED <br /> 0. 1�1 01 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 1 06 ALUMINUM ( ) 07 STEEL CLAD 1 1 OD BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> --._1 1 12 UNKNOWN l 1 13 OTHER: <br /> HSC04-071185 PAGE 1 <br />