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STATE ID NUMBER <br /> r <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE (TANK — — 1 <br /> I I O1 NEW PERMIT " f ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED t 1 09 DELETE FROM FILE (ND FEE) I <br /> 1 1 02 CONDITIONAL PERMIT f 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) J$ <br /> I OWNER — — --- --- <br /> NAMESCO POP ATION.IOIVIDUAL OR PUBLIC AGENCY) `r LP(U <br /> C AGENCY ONLY <br /> wG :-S - _. -- -- 1 FED { ) 02 STATE f 1 03 LOCAL <br /> STREET AC^KES-SA7 CITY �� STATr ZIP <br /> Wim'• - f/'„� -. <br /> II FA(' ILITY <br /> FACILITY Nd[RE a DEALER/FOPEMEN/SUPERVISOP <br /> STREET ACOESS NEAPEST CROSS STREET <br /> -- � <br /> CITY COUNTY TIP <br /> SO' HaILINC ADDP SS CITY STATE ZIP <br /> o t�6 <br /> PHONE W'ArEA CODE TYPE OF 1SUSINESS <br /> { O1 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER CF C'�NTAINEPS PUPAL AREAS ONLY TnW?[SHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS. NAhkE1LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 76 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. fl 01 TANK f ) 02 OTHER - - --- CONTAINER NUMBER <br /> -I -- — <br /> YEAR MFG: C. YEAR INSTALLED U�1 UNKNOWN <br /> B. MANUFACTURER [ IF APPRONRIATEI: �_. <br /> D. CONTAINER CAPACITY: fv <br /> GALLONS { ) UNKNOWN E. DOES THE CONTAINER STORE: ( } 01 WASTE ( 1 02 PRODUCT —- <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES f 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> [ s 01 U?ILEADEO ( 1 02 REGULAR { 1 03 PREMIUM ( } 04 DI SEL ( 05 WASTE OIL ( 1 06 OTHER, - <br /> V CONTAINER CONSTRUCTIONA. THICKNESS OF PRIMARY CONTAINMENT: ( I GAUGE 4 1 RICHES ( ) CM 1 ) UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) P4,1 02 NON-VAULTED f 1 03-UNKNOWN <br /> IC. f 1. 01 DOUBLE WILLED TP02_SINGLE WALLED f ) 03 LINED <br /> D. (DQE-CARBON STEEL f ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE f I 10 NON-METALLIC <br /> 1 12 UNKNOWN ( ) 13 OTHER: <br /> Fi�Cfl4-OiD185 PAGE 1 <br /> I <br />