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s•. <br /> - STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> NEW PERMIT ( ) 05 RENEWED PERMIT t 1 07 TANK CLOSED ( ) 09 DELETF.' FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT 1 ) 09 MINOR CHANGE INO SURCHARGE) <br /> I OWNER <br /> NAM!LCOVOCRATION,INDIVIDUAL OR FVBLIC AGENCY) PUBLIC AGENCY ONLY <br /> -�� b 1 ) 01 FED ( i 02 STATE ( 1 03 LOCAL- <br /> SS { Q CITY STATE <br /> ZI�/P-J� `r ( <br /> S T •L(V-.)--t..dLL.L ! V! t 1 S3 - lJ <br /> II FACILITY <br /> FAC LITY NAME DEA R/FGPEMEN/SUPERVISOR <br /> STFEET RDDtE S - NEA?EST CROS STPEET <br /> CITY COUNTY ZIP <br /> -� S �,-•, � a `�14 eT LJ <br /> MAUI L'DPESS l� � CI T)�_ STATE Zjj�� f+ fJ <br /> -- <br /> 0 <br /> PHO 'E W%AcEA CODE TYPE CF BUSINESS <br /> �. SOLINE STATION ( 1 02 OTHER <br /> NVfl5ER CF CONTAI14ERS PUPAL AREAS ONLY TOW14SKIP RANGE SECTION <br /> -- <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME( LAST ME FIRST} A D PHONE W/ REA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHON W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. TANK ( J 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG C. YEAR INSTALLED jq�5 ( ) UNKNOWN <br /> --- ----- —.--rT _ - -- ---cam.- � � <br /> D. CONTAINER CAPACITY: r0 �li 1GALLONS t 1 UNKNOWN FECOES THE CONTAINER STORE: ( 1 01 WASTE 02 PRODUCT <br /> F. QO STHE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( _) YES i 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED ( 102 REGULAR ( 103 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL t ) 06 OTHER �-- - <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINME)(T: 1 1 GAUGE I 1 INCHES f 1 CM 1 ) UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN Ati UNOERGROUr(D VAULT) t J NON-VAULTED 1 1 03 UNKNOWN <br /> JC. ( 1 01 DOUBLE WILLED I l SINGLE WALLED ( 1 03 LINED <br /> D. [ 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL { [WF-ISERGLAS5 ( 1 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> [ Y 06 ALUMINUM ( ) 07 STEEL CLAD 1 ) 0 R ma I ) 09 COMPOSITE [ ) 10 NON-METALLIC <br /> f 1 12 UNKNOWN [ 1 13 OTHER: <br /> H5C04-07D185 PAGE 1 <br />