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STATE ID NUMBER <br /> "'�` APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> L,YL.01NEW PERMIT ( 7 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> l 1 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OPINE <br /> I(NAME(COPPORATI@ INDIVIDUAL OR PUBLIC .4GENCY) _ PUBLIC AGENCY ONLY <br /> • t G _ ?s ( ) <br /> 01 FED ( ) 02 STATE 103 LOCAL <br /> STREET AD KESS ` /a# C Tyros- <br /> II FACILITY 11 STATE ZIP <br /> 3C,(l <br /> FAC IT NAME, a DEALER/FOREMAN/SUPE ISOR \ e^ <br /> . rr4 c — <br /> STREET AD RESS NEAREST CROSS JEREET <br /> 5(QO 5 . , w j �, <br /> CITY CDUNIY T a ZIP <br /> V C S <br /> WSJ" <br /> MAILING ADORES CITY '� STATE ZIP <br /> vd. l ra c. CiQ S3 <br /> P1111 W/AREA CODE TYPE OF BUSINESS <br /> ( 1 01 GASOLINE STATION 02 OTHER �( K.r <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NAME(LAST NAM FIRST) AND PHONE W/AREA CODE NIG,JS: NAME(LAS%NAME FIRST) AND PHONE W/AREA CODE <br /> C 1 20 -8�(o /G Sid 1(� n� 20 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( O1 TANK ( ) 04 OTHER: CONTAINER NUMBER �G24' 1 UNKNOWN <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: L. YEAR INSTALLED ,/ / T <br /> 0. CONTAINER CAPACITY:y GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE I`<02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 9.Jllr_Q1 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> UNLEADED ( ) 02 REGULAR f 1 03 PREMIUM 1 ) 04 DIESEL ( ) 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( I INCHES ( ) CM ('UNKNOWN <br /> B. l 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) . ler 02 MON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED kr 02 SINGLE WALLED l 1 03 LINED <br /> D. 1 ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> s ) 06 ALUMINUM 1 ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> IYI 12 UNKNOWN ( ] 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> II � • <br /> 1 . <br />