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jj4 k <br /> �OVAOSTATE ID NUMBER <br /> APPLICATION R PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f O1 NEW PERMIT [ l 05 RENEWED PERMIT E7C1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 ! 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT OQ MINOR CHANGE (NO SURCHARG <br /> I OWNER <br /> NAME_ COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> i ZJ ( l 01 FED <br /> f l 02 STATE ( ) 03 LOCAL <br /> STPEET ACnRESS •p� CITY_ STATE ZIP` „6 <br /> II FACILITY. <br /> FACILI Y NAME DEALEfr/FCPEMEN/SUPERVISO. R <br /> _ ��c�e, � e� Zf �l1 � <br /> STREET AOMPESS NEAREST CROSS STREET <br /> 7 c_)-Q <br /> CITY <br /> COUNTY ZIP <br /> Lo 8 <br /> MAILING ACOPESS CITY STATE Z�P� <br /> PHON`.WiPs�COOE����` TYPE OF f3USINE55 U ( l QI GASOLINE STATION f ! 02 OTHER <br /> NUMBER OF 9CONTA.INEPS PUPAL AREAS ONLY TOWNSHIR RANGE SECTION <br /> l <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME{ LAST NAME FIRST AND PHONE W/AREA CODE NIGHT ME(L�TNAMEFT1 AND PHONE W AREA GODS <br /> { , `e <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 O1 TANK I ) 02 OTHER. CONTAINER NUMBER <br /> B, MANUFACTURER (IF APPROPRIATE! YEAR MFG= C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: .30 O GALLONS 1 ) UNKNOWN E. DOES THE CONTAINER STORE' f ) O1 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHI Lf FUEL OR WASTE OIL ? (4} 01 YES ( ! 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ! 01 UNLEADED ( ) 02 REGULAR IN 03 PREMIUM ( ) 04 DI EL E ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> F <br /> HICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( 1 CM f ) UNKNOWN <br /> ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) rj 02 NON-VAULTED ( ,l 03 UNKNOWN <br /> IC. f ] 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. 01 CARBON STEEL 1 ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER <br /> -� PAGE 1 <br /> HBC04-070185 <br />