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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT l l 05 RENEWED PERMIT 1 ) 07 TANK CLOSED 1 l 09 DELETE FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT l l 06 AMENDED PERMIT 1 ) OC MINOR CHANGE (NO SURCHARGE) <br /> i OWNER _ <br /> )NAM EiCORPORATION.INO IVIOVAt OR PUBLIC A" <br /> NCYI PUBLIC AGENCY ONLY <br /> 01 FED ( l 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS . CITY STATE ZIP <br /> -Fb a?-yx� <br /> II FACILITY <br /> 'FA^IL' N MEOEALER/FOPCMEN/SUPEPV S R <br /> A _ Sc�,� 11 VL <br /> ,STREET ADDo SS/ NEAREST CROSS STREET <br /> C=Ty�o COUNTY Q :IP SL 6 <br /> \J o <br /> �AILINO ADDRESS CITYST er- .E ZIP <br /> 7` - <br /> ',NONE W/AREA CODE TYPE OF 6USINESS <br /> 01 GASOLINE STATION ( 02 OTHER ;wCa� k- <br /> �v.M69P OFZC/ONTAINEECPS RURAL AREAS ONLY TOWNSHIP RANGE SCCTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> 'AYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMCf)AST NAME FIRST) AND PHONE WARE <br /> CODC <br /> Sasrt• - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. YJ 01 TANK f l 02 OTHER: CONTAINER NUMBER 1 #y`r <br /> Fi <br /> B. MANUFACTURER (IF APPROPRIATE): •v // YEAR MFG VA� C. YEAR INSTALLED G 1 1 UNKNOWN <br /> 10. CONTAINER CAPACITY: GALLONS 1 1 UNKNONN E. DOE9 THECONTAINER STDRE: f 1 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR NA TE OIL ? ( ) 01 TES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( I 04 DIESEL ( ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> 1. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( 1 INCHES ( ) CM lki UNKNOWN <br /> E_I 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) X 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. <br /> 1 1 01 DOUBLE WALLED fp 02 SINGLE WALLED t ) 03/LINED <br /> 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE t 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM l ) 07 STEEL CLAD t ) OB BRONZE I 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> f ) 12 UNKNOWN l ) 13 OTHER: <br /> PAGE. 1 <br /> e <br />