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• • STATE ID NUMBER 115 /ODoZ <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> V�*Ol NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> [ 1 02rC M8&WeNAL PERMIT ( 1 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> AME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> �} 1 0% e,kS ( ) 01 FED f ) 02 STATE 03 LOCAL <br /> TPEET AO. ESS CITY STATE ZIP <br /> 3 00 5- S76-t L 7JAI G/f �ZG3 <br /> I FACILITY <br /> FACILITY NAME OE4LER/FOPEMEN/5UPERVISOP <br /> STREET ADDIESS NEAREST CROSS STREET <br /> Zq 0z <br />�'.CZTV COUNTY ZIP <br /> SAS QSzd <br /> D iTATE ZIP ADDRESS CITY S <br /> PHONE <br /> W/APEA CO(D}E TVP OF BUSINESS <br /> - - �j0 l ./ Z—3 13 ) O1 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CONTAINERS ^ RURAL AREAS ONLY TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAY,E)LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> N n <A-Te- ZoIr- 62- �Q Zo -ySr7~22 <br /> OLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (!p 01 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): SIC YEAR MFG: C. YEAR INSTALLED K) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS f 1 ;;;KNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (kl 02 PRODUCT <br /> F. DOES THE CONTAINER §T6RE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> ( ) 01 UNLEADED 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE JXL,INCHES ( ) CM ( ) UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) r)Q 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ) 02 SINGLE WALLED 1 ) 03 LINED <br /> D. 1�6 O1 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br />(SC04-070185 PAGE 1 <br />