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STATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> I <br /> 01 NEW PERMIT t 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 Olt-DELETE FROM FILE INO FEET <br /> 102 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE IND SURCHARGE( <br /> I OWNER --- - -- ---- — -- <br /> NAr.•ICOPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED 1 1 02 STATE 1 1 03 LOCAL <br /> STREET ♦COVESS ( 1pc ----_—___-- _.__ CITY STATF 2IP <br /> [1 _ Got7 4'rz <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMENYSUPERVISOP <br /> STREET ADD'ESS NEAREST CROSS STREET <br /> � 1AMA _ <br /> C: Y COUNTY IIP <br /> - --- — <br /> MAILING ADDRESS csrr STATE ZIP <br /> .. ��-ACV 2&Fe <br /> PHONEW•AP A CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION 02 OTHER <br /> NUYDER CP LCONTAINED$ PUPAL AREAS ONLY TOWNSHIP RANGE SlCTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NArEILAST NAME FIPST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (k) 01 TRM ( 1 02 OTHER _ _ _ - ONCTAINER NUMBER <br /> - <br /> B. MANUFACTURER (IF APPROPRIATEI: YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> 0. CONTAINER CAPACITY: 90-0 GALLONS ( 1 UNKNOW)) E. DOES THE CONTAINER STORE: 1 1 01 WASTE 1 A 02 PRODUCT <br /> F. DOES THE CONTAI14ER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BO%(ESI: <br /> 1 1 01 U1ILEADED (L 1 02 REGULAR 1 1 03 PREMIUM 1 1 04 DIESEL ( 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. 1H.10.HESS OF PP.IMARY CONTAINMENT l I GAUGE i 1 INCHES 1 ICM <br /> IKOW <br /> M UNKIWN <br /> _- .-N <br /> B. l 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 6e) 02 NON-VAULTED 1 1 03 UNKNOWN <br /> I 1 01 DOUBLE WILLED I 1 02 SINGLE WALLED 1 1 03 LINED <br /> ID. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 F16EPGLASS I 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD I 1 08 BROt12E i 109 COMPOSITE ( 1 10 NON-METALLIC <br /> 1�) 12 UNKNOW)) l 1 13 OTHER <br /> PAGE 1 <br /> N SC04-Oi^105 <br /> t <br />