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r <br /> % % <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> _ ( ) 09 DELETE FROM FILE (NO FEE <br /> tr <br /> 01 NEW PERMIT ( ) 05 AMENOED PERMIT ( } 07 TANK CLOSED <br /> ( } 02 CONDITIONAL PERMIT ( 1 Oo ACSEhT3ED PERMIT ( } 08 MINOR CHA}+GE (NO SURCHARGE) T <br /> ------------------- <br /> I OvJNER - --� <br /> --- �� PUBLIC AGENCY ONLY <br /> NAM 9; ORATION, NDIVIDVAL OR PUBLIC AGENCY) — t ) {yl fEp ( } 42 STATE ( 43 LOCAL <br /> —/j' r CI5�L STA ZIP <br /> STREET AD KESS 4,;_ ) ] �,.,� , <br /> y a�" rVIL <br /> II FACILITY <br /> DEAL RI/FOREMAN/SUPE VISOR <br /> FAC IITY NAME � �p br R <br /> NEAREST CROSS STREET <br /> STREET A DRESS <br /> q S' (y^� 1� ' <br /> S \Y► V Z <br /> IP <br /> eau v s <br /> CITY-„_, � V'\ G <br /> STATE ZIP <br /> / /V CIT1K�^ 7 <br /> MAILINGAD <br /> �1lJRE L lJ J <br /> z <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATIOPI02 OTHER <br /> — RnN�g SECTION <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP -` <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DA1' NAME(L ST NAME FIR571 AND PHONE W/AREA CODE NIG T5:�NAM£(LAST NAME FIRST) ANO PHONE WIAREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION --- <br /> CONTAINER NUMBER -- <br /> rMANWUFACTURER <br /> K ( ) 04 OTHER: --f —� _ <br /> (IF APPROPRIATE): -_ _ YEAR MFG= C. YEAR INSTALLED f� UNKNOWN <br /> CAPACITY: Q GALLONSUNKNOWNJE. DOES THE CONTAINER STORE: { } 01 WASTE2 PRODUCT <br /> CONTAIfdER STORE MOTOR VENICLL` FUEL OR WASTE OIL ' 01 YES f } 02 NOIF YES CHECK APPR{PR RTE @OXtES):LEADEp ( 1 02 REGULAR t i 03 PREMIUM ( 1 04 DIESEL ( } 05 WASTE OIL Ly 06 OTHER y�►G�. Id <br /> V CONTAINER CONSTRUCTION <br /> r <br /> OF PRIMARY CONTAINMENT: <br /> ( ] GAUGE ( 1 INCHES ( 1 CMUNKNO4dN �— <br /> ULTED (LOCATED IN AN UNDERGROUND VAULT) (� _02 NON-VAULTED ( ) 03 UNKNOWN <br /> UBLE WALLED QJ1102 SINGLE WALLED ( } 03 LINED <br /> D. R@ON STEEL [ } UZ STAINLESS STEEL t } 03 FIBERGLASS ( } 04 POLYVINYL CHLORIDE t ) 05 CONCRETE <br /> ALUMINUM l } 07 STEEL CLAD ( ) 05 BRONZE ( } 04 COMPOSITE ( } IO NON-METALLIC <br /> KtjOja} f } 13 OTHER: _— — <br /> �� PAGE 1 <br /> HSC04-074185 <br />