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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (xl OI NEW PERMIT ( 105 RENEWED PERMIT (A 07 TANK C SED g 0 d f ) 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) 04 MINOR CHANG NC1 URCHARGE) <br /> I OWNER <br /> NAMEfCORP ORATION,INDIVIDUAL OR PVBLIC AGENCY) 1 PUBLIC AGENCY ONLY <br /> G ( r ( ) 01 FED ( ) 02 STATE l 1 03 LOCAL <br /> STREET ADDRESS �/ CITY STATE ZIP <br /> e[,/a )- 9 10 <br /> d <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> 10 Mr <br /> STREET AODPESS NEARS T CROSS STP.E T - <br /> f � <br /> CIT COUNTY ZIP <br /> To 9 S2 <br /> MAILING G�FESS CITY STATE ZIP_�� <br /> PHONE W%APEA CODE TYPE OF BUSINESS <br /> S' it ( 1 01 GASOLINE STATION (o 02 OTHER k/wd Re,5ervd4lor\ <br /> NUMBER OF N CONTAINERS RVRAL AREAS ONLY IT <br /> RANGE SECTION <br /> L�/ / <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,E(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> skiba-, La,rty 58 1 209ys��� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (%,Y01 TANK ( ) 02 OTHER: CONTAINER NUMBER Q <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (_<,4 NKNOWN <br /> D. CONTAINER CAPACITY: !2� GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: f 101 WASTE Ql<' 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ()K) 01 YES ( l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM De 04 DIESEL f 1 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM Od UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) tXr 02 NON-VAULTED l ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (M 02 SINGLE WALLED ( ) 03 LINED <br /> D. 04'01 CARBON STEEL f ) 02 STAINLESS STEEL ( 1 03 FI6ERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD [ 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />