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/ • STATE IO <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGk,iTANK �«<,,; , `; <br /> 1 1 O1 MEN PERMIT 1 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED 1 1;00 OELETO.FROM fIkf._,ltK0,J ft <br /> _1 1 BE CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 06 MINOR CHANGE (NO SURCHARDEI <br /> I OWNER _ <br /> NAnt(COPPORATION.INDIVIDUAI Of PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 01 FED 1 1 O2 STATE ,l 4 03;LOCAL <br /> fTrt[1 ADOR[Si '' +. .. -Tc,TV siAT[. .. 2IFa Y its' <br /> t 3t� 35 F' - I')'IR(n/ U°.t7 . �'30� 5523 S7ocKTonl <br /> ` II FACILITY <br /> FACILITY NAME Of AtER/FOREMEN/SUPERVISOR <br /> W/qTEfz to. M />r ✓Z KET dd 2q I LL <br /> STREET ADVIESS NEAREST CROSS STREET <br /> / 05// 5 £ . WR TER Loa C0A& sToe 1t <br /> CITY COUNTY zip <br /> .57-ockrtl SRA/ roAQLtCAI <br /> 19 15 <br /> MASt INO ADDRESS - -- '^ CITY -' ., STATE IIP <br /> PHONE W•'ARRA COOC TYPE O/ BUSINESS - - <br /> 709- 93/- G le, -7 l✓1'01 GASOLINE STATION (- 1 02 OTHER YY\A x IL✓_ T <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY TOWNSXi1 RANGE SCCTION. <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> ---- - - -- <br /> DATf• NAMCt LAST NAME FIPSTI AND PHONE N/ARCA COD[ NIGNTfi NAMCI)AST NAM[ FIRfT,I AND PHONE N/ARCA CODE <br /> I COMPLETE THE' FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER .. , <br /> IV DESCRIPTION <br /> A. 10 01 TAMC ( I Of OTHER I, At N L44 dG d GF}f ! CONTAINER NUMBER <br /> B. MAIA)FACTURER (IF APPROPRIATE It _.. . : L—t N K Ai f LI/ Al YEAR MFG: C. YEAR INSTALLED-___- (,1 Uta(HONN <br /> G. CONTAINER CAPACITY: 'V• OtD 0 GALUBIS 1 i UNKNOWN1. DOES THE CONTAINER STOREt ( 1 01 WASTE (11 02 PRODUCT <br /> F. DOES THE CONTAIIIER STORE MOTOR VEHICLE FUEL OR WASTE OIL T 1 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> I t.Y01 UILEAOCD ( 1 02 REGULAR 1 '1 03 PREMIUM 1 1 04 DIESEL l 1 OS WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: l 1 GAUGE 1 1 INCHES 1 1 CM (-l_URCNOWH - <br /> B. 1 1 01 VAULTED ILOCATED III AN UNGERGROUN VAULT) '1 1 02 HON-VAULTED (-,) 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE WILLED 1�'1 02 SI14GLE WALLED ,1 1 03 LINED <br /> D. 1 1 01 CARBOII STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE 1 1.05 COIKRETE <br /> 1 1 06 ALUMIIAIM 1 1 07 STEEL CLAD 1 1 00 BROIIZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC - <br /> It/( 12 LRKHOMI ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />