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% % <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> E <br /> l NEVI PERMIT ( ) 05 RENEWED PERMIT f 1 07 TANK CLOSED ( ) 04 pELETE FROM FILE (NO FEE) <br /> ) 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT E ) 08 MINDR CHANGE IND SURCHARGE) <br /> I GONER <br /> --- —�- -_. PUBLIC AGENCY ONLY <br /> NAME C�7 PORATIC�NDIVI UAL OR PUBLIC AGENCY) ( ) 01 FED ( ) 02 STATE #4:J-03 LOCAL <br /> C'TYr STATE ZIP <br /> STREET Al FESS / y 7 G <br /> 3z�5 <br /> II FACILITY <br /> FACIL NAME <br /> mo�`+� �DEA ERIFOREMAN/SUP RVISOR <br /> TY u ' <br /> NEAREST CROSS STREET <br /> STREET AD RES) !A/']r /� � <br /> C ,n <br /> Ll <br /> ' '< ZIP <br /> CIT 1 53 <br /> ixn <br /> `J STAT ZIP <br /> CITY <br /> MAI C ADDRE S <br /> p}yONE W/AREA CODS <br /> TYPE OF BUSINESS <br /> ��--- �( ] 01 GASOLINE STATION 02 OTHER <br /> RANGE SECTION ----- <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP — Tv� <br /> III 24 'HOUR EMERGENCY CONTACT PERSON <br /> pq}'$• NAMlSLA T N ME FIRST) AND PHONE WfAREA CODE NIG TS: NAMEfLAST NAME FIRST) AND PHONE W/AREA CODE <br /> sz <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION — -- — — a <br /> --'--- –��— _-- L_FG_ <br /> CS)NTANUMBERrDOES <br /> TANK t ) 04 OTHER: �YEAR INSTALLED UNKNOWN <br /> CTURER fIF APPROPRIATE): _ 71C <br /> NER CA <br /> ✓c7 �GALLONS [ ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE_(30'02 PRODUCT <br /> 'HE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? Dd O1 YES ( ) 02 NO IF YES CHECK APPR PRIATE BOX(ES)UNLEADED t ) 02 REGULAR t ) 03 PREMIUM t ) 04 DIESEL t ) 05 WASTE OIL (%l 06 OTHER ( h <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) G,5UGE ( ) INCHES ( ) CM (V UNKNOWN <br /> B. t ) 03 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (\02 NON-VAULTED t ) 03 UNKNOWN <br /> C. L ) O1 DOUBLE WALLED (k1 02 SINGLE WALLED ( ) 03 LINED <br /> D. t ) 01 CARBON STEEL E ) 02 STAINLESS STEEL f ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE_ f ) 05 CONCRETE <br /> ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ] 09 COMPOSITE E ) 10 NDN-METALLIC <br /> f „12 UNKt4o:jN ( ) 13 OTHER' <br /> PAGE 1 <br /> HSC04-070185 <br />