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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> --- ( ) 09 OELETt FROM FILE (NO FEE1 <br /> ( 1 1 NEW PERMIT ( 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED <br /> 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE SND SURCHARGE} m-- - <br /> - - -- - --- -- -� PUBLIC AGENCY ONLY <br /> NAM!ICOPvORATION.INOIVIDUAL OR PUBLIC AGENCY) � 1 1 OI FED 1 1 02 STATE l 1 03 LOCAL <br /> C��i 4GI Thi - - <br /> CITY /�� ,r,�J STATE ZIP <br /> ISTP!ET AC7RE+ %� 't+ 3 <br /> �.�' d _ S� .�--_ <br /> II FACILITY - <br /> DEALER/FOPEMEN/SVPEPVISOP <br /> ►AGILITY NAME <br /> fj <br /> STREET ADC�ESS , M NEAPEST CROSS STPEET -,/ <br /> COUNTY <br /> ' ZIP S �� <br /> CITY yrll Al (1 a ._. <br /> CITY STATE ZIP <br /> MAILING 60a r ei <br /> 2/ <br /> PHON_ W-ATEA CODE TYPE OF 6USIN!SS v y i; <br /> ) 0 <br /> 1 GASOLINE STATIQN ? 02 OTHER (f G1 7 <br /> 7 / PUPAL APEAS ONLY T�SWNS+;IP PANGE SECTION <br /> NUr4E• Cf C7NTAIE�PS -- <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEILAST NAME FIRST) AND PHONE W/APER CODE ' NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> E <br /> COMPLETE THE FOLLOWING ON A SEPARATE 'FORM FOR EACH CONTAINER <br /> IV DESCRIPTION - �- <br /> A. 01 TANK i 1 02 OTHER: <br /> CONTAINER NUMBER <br /> e. MANUFACTURER (IF APPROPRIATE)! YEAR MFG- C. YEAR INSTALLErLI [_) UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE l ) 0022 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? I 1 01 YES t ) 02 NO IF YES CHECK APPROPRIATE BOX(ES) <br /> 1 1 01 UNLEADED ( 1 02 REGULAR 1 1 03 PREMIUM IKI 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTIONA. THICKNESS OF PRIMARY CONTAINMENT; ( I GOUGE ( 1 INCHES ( 1 CM l 1 UNKNOWN <br /> 01 VAULTED (LOCATED IMI AN Ut40ERGR0U1fD VAULTI 1 1 .02 NON-VAULTED 1 3 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE WNLLE0 '62 SINGLE WALLED -( 1 03 LINED <br /> f0. ( I C-ARGON STEEL ( 1 02 STAINLE55 STEEL ( M 03 FIGERGLASS f 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 ( 1 06 ALUMINUM ( 1 07 STEEL CLAD 1 I 08 13RO117-E ( 1 09 COMPOSITE 1 1 10 NON-METALLIC - <br /> 1 1 12 UNKNOWN ( ) 13 OTHER: - <br /> --- ---- — -- - -- --- - - -- PAGE 1 <br /> HSC04-070185 <br />