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• 0 STATE,IO NUMBER? L� <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGETANX <br /> ( 1 01 NEN PERMIT l 1 OS RENEWED PERMIT 1 1 07 TANK CLOSED 1 I,OO OtttTC.F,ROM P,�L!ttlFL,FEE I <br /> .. .(. 1 Ot CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 OB MINOR CHANGE IND SURCHARCEI <br /> 6 EINTAL.HEALTH. <br /> ENVIRQ <br /> I OWNER _ �«t 'ERVICES <br /> NAn%(CORPORATION.IMDIVIOU&% 0R PUSIIC AOtNCYI PUBLIC AGENCY ONLY - <br /> d'. of - W L N c-I P-11 a- S O N f 1 1 O1 FED 1 l OL STATE ,l r1 OS LOCAL <br /> STREET AVORISf ... . a. CITY - STAT[. . IIFy.y ,t <br /> 3a35 'Y1'IA-�-n7 P-rJ . ,3cJl 557.3 S7ocK'ro&`l ..,Cf1 <br /> ` II FACILITY <br /> FACILITY NAME O[AIER/IOR[M[N/fVPC1VISOR <br /> W,j r£a LPe Mart KEr 73dd 2a ,u 61,4-LL <br /> STREET AOCKSS NEAREST CROSS STREET <br /> / Ov15 ECoAtisTocK <br /> CITY --- COUNTY IIP <br /> 57-oclC7-0 SrIA/ TOA &eu ('A/ 95zo5 <br /> "AILING ADDRESS '- CITY <br /> .._ TAT <br /> —I ] <br /> . . EI/ <br /> PHONE WAARCA CODE TYPE OF RUf INI95 - - <br /> 709- /j 3/- G 10 -7 1-1'01 GASOLINE STATION ( 1 02 OTHER -- Y>1,4 oe X E- T <br /> NU BER CP CONTAINERS RU[At AREA! ONLY t TOWNSHIP PANGS - iCCTiON,, <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS• NAn[1 LAST NAM[ PIPSTI ANO FHON! W/ARCA COOL MIONT$$ MAMtI LAST MAM! FSRST;1 AND PMONt W/AREA CGOC <br /> 1 . <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER _ . <br /> IV DESCRIPTION <br /> A. (✓` 01 TALK- I 1 OL OTHERt• Re9 u,LF/C G q s CONTAINER NUMBER ,Z - <br /> B. MA14 UFACTURER (IF APPROPRIATEI& -_ Ll. Al ZI NC .I til - YEAR MFG& C. YEAR INSTALLED- - (-T UWHOW1 <br /> 0. CONTAIIIER CAPACITY: /®/6,610 GALLOf19 i i UNKf(OIOI' E. GOES THE CDN7AINER STORE= 1 1 01 WASTE I -f 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES l 1 02 NO IF TES CHECK APPROPRIATE BOK(ES1: <br /> l 1 01 UNLEADED l✓1 02 REGULAR ( '1 03 PREMIUM l 1 04 DIESEL 1 1 OS WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 1 INCHES 1 1 CM (.f`UNKNOWN <br /> IB. 1 1 Ol VAULYEO (LOCATED IN AN U(OERGROUD VAULTI '1 1 02 NOH-VAULTED Iwl 03 UNKNOWN <br /> C. 1 1 Ol DOUBLE WALLEO 14 02 SINGLE WALLED ( 1 03 LINED _-- --_------- ___._ _ <br /> D. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1. 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 06 BROHZf 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1✓1 12 UNKNOWN ( 1 13 OTHER: <br /> 11SC04-070165 PAGE 1 <br />