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• STATE I MEaRR V <br /> J APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE 74'ffk11 1981 <br /> ( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09fs WRQk*NTALEHEAL") <br /> ( 1 02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (ND SURCHARGE) FERMIT/SERVICE <br />[ OWNER <br /> NAME OPPORATION. NCIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ,!-IFFACILITY. G rdo l 1 01 FED f ) 02 STATE ( 1 03 LOCAL <br /> RE S %3 cyI <br /> FACIL TY NAY.E� DEALER/FOREMEN/SUPERVIS <br /> L <br /> ➢JOU Ct F12 <br /> STREET POD-ESS NEAREST CROSS ST P.EET <br /> p Ce o m 0L rel O ` 5 <br /> COUNTY ZIP SJ <br /> CITY � <br /> Q.. <br /> q_ �1 J�CITY �1 STATE ZI$j �^0/p <br /> MAILING ADDPESS l/A,C(]- <br /> PHONE W,A EA CODEJ TYPE OF BUSINESS <br /> S �� ( 1 01 GASOLINE STATION lX) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEf LAST NAME FIPST7 AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. Ol TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): U)jI YEAR MFG: C. YEAR INSTALLED (1�LNKNOWN <br /> D. CONTAINER CAPACITY: 16 pQ(J GALLONS 1 ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE A 02 PRODUCT <br /> F. DOES THE CONTAINER JTORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES [ ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL l 1 05 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION / <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (1Y� l MOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> O1 DOUBLE WALLED 1 02 SINGLE WALLED l 1 03 LINED <br /> �-0. l ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 06 BRONZE ( 1 09 COMPOSITE ( l 30 NON-METALLIC <br /> L lP/f 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />