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STATE ID HUMBER <br /> APPLICATION FOlIPERMIT TO OPERATE UNDERGROIRD STORAGE TANK <br /> i <br /> I 1 <br /> 01 NEW PERMIT l 1 05 RENEWED PERMIT l 1 07 TANK,CLOSED l 1 09 DELETE FROM FItE IND FEET <br /> 1 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 1 00 MINOR CHANGE (No SURCHARGE) <br /> i a <br /> j I O W N E R ------ -- <br /> NAMEICOPPO//RATION,INOIVIDUAL OR PUBLIC AOENCY) PUBLIC AGENCY ONLY <br /> ___-NO E _�S T G ( 1 01 FEB 1 1 02 STATE l l 03, LOCAL; <br /> STREET ACnRESS - CITY STAT! LIP <br /> i / Os rE /Ptd � ��' }! C�/� T4 <br /> II FACILITY _ <br /> FACILITY NAME " <br /> DEALER/FOREMEN/SUPERVISOP <br /> ' e4RTiss PoN7-/ G ,[tAa G..rre. G✓�Aey G' aer_/s s- •r te <br /> i — <br /> STREET AOO'ESS NEAREST CROSS STREET , <br /> CITY COUNTY IIP <br /> ,,PR ' 5 .� '��' 4 u /.IJ: --- 95-376 <br /> ';4, MAILING AODPESS CITY • STATE LIP <br /> T-P,9e �/,� 95 3 7/, <br /> - <br /> PHONE W•AVEA CODE TYPE OF BUSINESS <br /> ( ) 01 GASOLINE STATION l_02 OTHER ,Ju TO/ndfl✓�E JAG RLEi1'=h'��_, <br /> NUMBER CE CONTAINEPS RURAL AREAS ONLY TOWNS NIR RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> IIIrO ATS: NAY,E(LAST NAME FIPSTI AND PHONE W/APEA CODE NIGHTS: NAMEILAST NAME FIRST)-AND-PHONE W/AREA CODE. <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1 IV DESCRIPTION <br /> I <br /> A. (/01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE D YEAR MFG: J'L� C. YEAR INSTALLED- �D 1 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: 1%611✓ GALLONS l 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 11PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> 1 1 01 UNLEADED ( 1 02 REGULAR 1 ) 03 PREMIUM 1 1 04 DIESEL. 1. 1. .05 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION _ <br /> IIr4 A. THICKNESS OFPRIMARYCONTAINMENT: 1!q GAUGE ( I INCHES 1 1 CM l 1 UNKNOWN <br /> S. ( 1 01 VAULTED )LOCATED IINANUNDERGROUND VAULT) ( 02 NON-VAULTED 1 1 03 UNKNOWN <br /> C. f 1 01 OUBLE WILLED 1 W'02 SINGLE WALLED 1 1 03 LINED — <br /> I0. 1 01 CAR0011 STEEL ( ) 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> ( 1 06 ALUMINUM 1 1 07 STEEL CLAD l l 08 BRONZE 1 1 09 COMPOSITE l 1 10 <br /> t ) 12 UNKNOWtI l 1 13 OTHER: Fr <br /> - <br /> ... --'------._.---------- ---- -- --- �..' . <br /> H5C04-070185 '� PAGE, <br /> NOV 2 198? <br /> ENVIROMENTAL HEALTH <br /> PERMIT/SE:VICES <br /> L <br />