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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ('A'01 NEW PERMIT ( 1 05 RENEWED PERMIT l 1 08 TANK CLOSED <br /> l 1 09 DELETE FROM FILE IND FEE) <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAM'_(COP ORATION.I(oNDIVIDVAL OR FVBLIC AGENCY( PUBLIC AGENCY ONLY <br /> 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> �ER <br /> 1 AT ZIP <br /> �� <br /> STREET ADDRESS - 3 <br /> — _A <br /> II FACILITY <br /> DEALER/FOPEMENISUPERVISOP <br /> FACSIIT NOME ' � - � <br /> �`,A I-J <br /> STREET ADD-ES NEAREST CROSS STREET <br /> 0 , Banc — <br /> CITY A- � l/` Q COUNTY ZIP� T (��z_ <br /> CITY !,• STATE /ZIP <br /> j MAILING ADDRESS—" <br /> PHONE WIAFEA CODE --Y TYPE OF BUSINESS <br /> -�A rq 0 c 3 O ( ) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF CONTAIN PS <br /> RUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> �DAYS: NAMM.EfLAST NAME FIRST) AN Pf10NE W//ApEA�¢O Fes,. NIGHTS: NAME l(AST NAME_FIRST 1-A�-PX07E W/A oC O <br /> _ J Zik /v-1. OQQ/ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> ?•. A. 1 1 01 TAM ( ) 02 OTHER: CONTAINER NUMBER _ <br /> B. MANUFACTURER IIF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED tefT7 l 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 30 GALLONS 1 ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE l 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? f 1 0 YES I l 02 NO IF YES CHECK APPROPRIATE BO%(ES1: <br /> ( ) <br /> 01 UNLEADED ! 1 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL 1(A) 05 WASTE OIL 1 ) 06 OTHER___ <br /> V CONTAINER CONSTRUCTION <br /> I`rA. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE [ ) TACHES ( ) CM l 1 UNKNOWN _ <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. 01 DOUBLE WILLED 1 1 02 SINGLE_WALLED l 1 03 LINED <br /> D. 1 1-_11 O1 CARBON STEEL l 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD (BONZE 1 1 09 COMPOSITE ( 1 30 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> H5C04-070185 <br />