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V-4;& STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> fAl 01 NEW PERMIT ( ) 05 RENEWED PERMIT07 TAN( CLO ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT l ) OB OR ANGE (NO SURCHARGE) <br /> I OWNER �y.�� <br /> NAME(COPPORATION,INDIVIOUAL OR PUBLIQ AGENCY) 4 PUBLIC AGENCY ONLY <br /> ✓l rh V- ( ) O1 FED ( ) 02 STATE f�Q'03 LOCAL <br /> STREET ADDR E$$ n C //m CITYq Q�', STATS 2IV l �� <br /> I I FACILITY <br /> C�J / /(/f c� K !/_ <br /> ?AERVISOR <br /> C ITY NAME EAL�ER/FOREMAN/ UP <br /> STREET ADORENEAREST CP S STREE <br /> am S <br /> E , in <br /> CITY COUNTY T IIP <br /> N SQ <br /> MAILING ADDRESS . CIT ' STATE LIP <br /> 3 r S2 <br /> PRONE W/AREA CQDE ` �/ TYP OF BUSINESS '/ - p <br /> fel-l�J I/O- ( ) 01 GASOLINE STATION tt 02 OTHER S GC.I W 4; <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS• NAME(L_S,T NAME FIRST) AND PHOS W/APEA COLE NIOXTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> �rori , Jo�ll U, X09 Sf1 ale TT�JJ+ FI�� _' Y V. 2y9-36S Qty/I <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (kr 01 TANK ( ) 04 OTHER: CONTAINER NUMBER Q� <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: /d=GALLONS ( I UNKNOWN E. DOES THE CONTAIO1 WASTE ( 02 PRODUCT <br /> CONTAINER STORE: ( 1 <br /> F. DQESOI UNLEADEONE_R 5—TORERE MOTOR VEHI SLE FUEL O PREMIUM 04LOIE 0( )E 05 WASTE2NO OIL (I) 06SOTHERK APPROPRIATE BOX(ES): <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM ) UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (/J 02 NON-VAULTED ( ) 03 UNKNOWN <br /> ) <br /> C. t } 01 DOUBLE WALLED 02 SINGLE WALLED 1 ) 03 LINED <br /> D. (&1 0; CARBON STEEL <br /> ) 2STAINLESS SEL ( 03 FIBERGSpOLriioYLCH ( OS CONRETE <br /> T <br /> 06 ALUMINUM 07STEEL LLAO ( ) 08BRONZE09 COMPOSITE � METALLIC <br /> ( ) 12 UNKNOWN ( 113 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br /> r <br />