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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f I <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CEOSEO ( ) 09 DELETE FROM FILE (NO FEEI <br /> ( 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) -- — <br /> I OWNER <br /> NAME(coRROaAT ,ir+o xviou/.y OR PUBLIC PUBLIC pLIB LIC AGENCY ONLY <br /> _ G /�O` �G�+/.r�'L6 1 I Ol FED l 1 02 STATE ( ) 07 LOCAL <br /> S TPEET ADO ESS <br /> -- �j D A 14o <br /> NA'c ^ CIT STATE ZIP <br /> II FACILITY <br /> FACILITY NAME y/^ DEALER/FOPEMENISUPEPVISOP <br /> foLA -,k <br /> STREET ADD-ESSNEAREST CROSS STREET <br /> Q �Db/Adr5 ad , S7I� Chi GilF1L7� S <br /> CITY <br /> COVNTYI r <br /> 'Tc <br /> /`./_520S— <br /> I MAILING ADDP SS 5��pp <br /> , Og CITY S-TKN� GTfV STATE rz <br /> ZIP <br /> S <br /> PHONE WIPcEe ODE TYPE CF BUSINESS <br /> 57 l 1 O1 GASOLINE STATION 1 02 OTHER <br /> NUMBER CF CONTAI4EPS PUPAL AREAS ONLY TOW NS NSP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: ;M,E(LAST `ME fIPST) AND RHON�WAREA COD! NIGHTS: NAMlIIAST NAME FSRSTI AND PMONE W/AREA CO� �_A LGoQe- -ZZ '/-9S�S� - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> <'s A. (\01 TANK ( 1 02 OTHER: CONTAINER NUMBER �1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 19 IS�1 UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINE ORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES 1 ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> I 1 01 UNLEADED l 02 REGULAR f 1 03 PREMIUM f 1 04 DIESEL ( 1 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT ( ) GAUGE f ) INCHES ( I CM ( ) UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 ) 02 NON-VAULTED 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WALED vNo 02 SINGLE WALLED t 1 03 LINED <br /> D. f 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 1 06 ALUMINUM l 1 07 STEEL CLAD ( 1 OB BRONZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 1 1 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-07018S --_-- - --- PAGE 1 <br /> �� el <br />