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0 STATE ID NUMBER <br /> ( 1 09 DELETE FROM FILE (NO FEE) <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TAN <br /> ( ) O1 NEW PERMIT ( 1 05 RENEWED PERMIT t l 07 TANK CLOSED <br /> ( CONOITIONAL PERMIT PERMIT ( ) 0(1 MINOR CHANGE (NO SURCHARGE) <br />[ <br /> OWNER PUBLIC AGENCY ONLY <br /> Y: C� + ( ) O1 FED ( 1 02 STATE ( ) 03 LOCAL <br /> NAME(COPPORf\.TION.INDIVIDUAL R RUB IC AGE G STATE I P� <br /> l T() r_r\_L 01— e' CITY <br /> STREET ACOO SSW . <br /> / <br /> II FACILITY DEALER/FCREMEN/SUPERVISOR rre \a- "A <br /> ra�vLl z r r <br /> FACSLI'y ME r a <br /> ('Yt.LG`' ;e' NEAREST CROSS STREE <br /> STREET AOCRES f COUNTY 2I <br /> CITY c`J STATE ZIP <br /> S �- I <br /> CITY _ (, ( L/ r <br /> MAILInNG ADDRESSc/�T7�V <br /> r _U O <br /> TYPE OF BVSINESS ) 02 OTHER <br /> PHONE Wi AIEA CODE. a T ( ) 01 GASOLINE STATION t SECTION <br /> .^�AA L1� u RANGE <br /> YV RURAL AREAS ONLY : TOWNSHIP <br /> NUMBER OF CONT INE'S <br /> III 24 HOUR EMERGENCY CONTACT PERSON NI S. NAMEllPST NAME IRST) No H HE W/AREA C <br /> ODE <br /> --- T a ssvv/J1 O <br /> DAYS: NAME(LAST NAME FIRST) AN PHONE CODE O V r <br /> COMPLETE THE FOLA{1{{lLOWING <qo ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION CONTAINER NUMBER <br /> A 0( ( ) 02 OTHER: ) UNKNOWN <br /> YEAR MFG: C. YEAR INSTALLED <br /> B. MANUFACTURER APPROPRIATE) <br /> f UNKNOWN E. DOES THE CONTAINER STORE: ( ) O1 WASTE ) 0 PRODUCT <br /> D. CONTAINER CAPACITY: S 00 GAL S ( ) 02 NO IF YES CHECK APPROPRIATE BOK(E57 <br /> F. DO S T L l ) 05 WASTE OIL l ) 06 OTHER <br /> ONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL <br /> ( ) UNLEADED l ) 02 REGULAR ( 1 03 PREMIUM ( 1 04 0 <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: <br /> ( ) GAUGE f 1 INCHES ( ) CM UNKNOWN <br /> ( ) <br /> B. ( ] 01 VAULTED IN AM UNDERGROUND VAULT) (N0 NON-VAULTED ( ) 03 UNKNOWN <br /> C, ( 1 01 D SLE WALLED ( SINGLE WALLED ( ) 03 LINED <br /> 04 D. ( (0) 06R ALUMINUM07(( ))0725 TEEL STAINLESS STEILOBI BRO03 FISERG09SCOMPOSITE Pall 10YNON-METALLICL CHLORIDE ) ) 05 CONCRETE <br /> LAD <br /> ( ) PAGE ] <br /> 12 UNKNOWN ( 7 13 OTHER: <br /> HSC04-070185 <br />