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0 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 09 DELETE FROM FILE (NO FEE) <br /> NEW PERMIT ( 1 05 RENEWED PERIUT ( ) 07 TANK CLOSED <br /> 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (No SURCHARGE) <br /> OWNER <br /> PUBLIC AGENCY ONLY <br /> �AMEICOPPCPAt)[ON,INDIVIDUA OR PUB IC AGENCY) 01 FED I ) 02 STATE 03 LOCAL <br /> 3 STATE <br /> EET ACnR'SS <br /> FACILITY <br /> FA�JlTf NA�.E DEALER/FOPEMEN/SUPEP vcx:�L::id� <br /> STREET AOV-rS'S_ NEAP&ST CPC�S STREET <br /> fto,3-h V-- <br /> CITYS COUNTY ZIP <br /> CIT STATE zi <br /> MAIL NO AD PESS <br /> 0 <br /> LPN�GN. W,A�EA CODE TYPE OF SUSINES <br /> ( 1 01 <br /> r- GASOLINE STATION .02 OTHER Gx-rr,, <br /> �2 I- <br /> NU"EP CF C NTAINEPS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 111 24 HOUR EMERGENCY CONTACT PERSON <br /> LOA ME I LAST NAME FIRST) AND PHONE W/APEA CODE N1 PJE(LAST NAME FIPSTJ AND PHONE W/APEA COE" <br /> HIG <br /> _a - - <br /> k.L(R� - C�� LAXH!!�� _ <br /> Dak <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIFTION <br /> 02 OTHER: tCONTAINER NUMBER <br /> Y <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (XI UNKNOWN <br /> Y :EAR <br /> D. CONTAINER CAPACITY: V QgLL.GhLLOUS I UNKNOWN JE. D(ES THE CONTAINER STORE: WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 01 YES 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> 01 01LEADED 02 REGULAR t ) 03 PREMIUM I ) 04 DIESEL 'V� 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: I ) GAUGE INCHES CM UNKNOWN <br /> a. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) VAULTED t 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WkLLEO SINGLE WALLED 03 LINED — <br /> 0. CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> 06--A-L-U-M—INUM- 07 STEEL—CLAD--(_) 08 BROtJZE ( 1 09 COMPOSITE 10 NON-METALLIC <br /> UkKNOWN 13 OTHER: <br /> HSCO4-07�185 PAGE 1 <br />