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• • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 09 DELETE FROM FILE (NO FEE1- <br /> 1 1 <br /> 01 NEW PERMIT l -) 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> 1 1 02_CONDITIONAL PERMIT l 1 06 AMENDED PERMITMINO <br /> _ 1 ) O8 R CHANGE (N0 SURCHARGE) <br /> I OWNER - <br /> ---bbb"` PUBLIC AGENCY ONLY <br /> NAME ICOPPORAT.10N.INDIVIDUAL OR PUBLIAGENCY 1 ( 1 O1 FED ( ) 02 STATE l ) 03 LOCAL <br /> pi <br /> C y,. �` CITY STATE <br /> �Q-..IT / STATE ZIP / <br /> STREET ACnRES O EAJ aC C. WL ;Tr_ !'u G- y•'y � • ry IFCT <br /> II FACILITY _ <br /> DEALER/FOPEMEN/SUPERVISOR <br /> FACIy�TY NAME jL�l�, <br /> OC 1°t r� al Cf kc- C° ,r R <br /> NEARE CROSS <br /> STPEET y � <br /> STPEET FCC°ESS 1. 1 1 � .1 <br /> ��D W fA.( r ZIP j r �. <br /> COUN Y l 1 <br /> CITU K3 < I C 1(V <br /> -- STATE ZIP <br /> CITY <br /> i� MAILING ADDPESS <br /> ONE W/AeEa CODE L TYR f BUSINESS <br /> PHI v K t <br /> H �Z 3 - 7 o aS 7 ) O1 GASOLINE STATION f 1 02 OTHER <br /> P VPAL AREAS ONLY : TOWNSHIP RANGE <br /> SECTION <br /> NUMBER CF CONTAINERS — <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> NIGHTS: NAMCI LAST NAME FIRST) AND PHONE W/AREA CODE <br /> DAYS: NAME(LST NAME FIRST) AND PHONE W/AREA CODE - - <br /> IMM m . ` L-htoo,o9 4z3 -)o63 SAvkv <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION 0 C° qCCT "Tt4tjKI pie S f- <br /> Lt <br /> I <br /> CONTAINER NUMBER <br /> [DCONTAINER <br /> ) 01 TANK ( 1 02 OTHER: <br /> MANUFACTURER IF APPROPRIATE Y• YEAR MFG: YEAR INSTALLED ( 1 UNJESr- <br /> C. <br /> CAPACITY: GALLONS 1 ) UNKNOWNE. DOES THE CONTAINER STORE: ( 1 O1 WASTE t 1 02 PRODUCTDOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 O1 TES l 1 02 NO IF YES CHECK APPROPRIATE BO <br /> 1 1 <br /> 01 UNLEADED l 1 02 REGULAR ( ) 03 PREMIUM ( 104 DIESEL f ) 05 HASTE OIL 1 1 06 OTHER_ <br /> V CONTAINER CONSTRUCTION <br /> FA. HVCrNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( 1 INCHES t 1 CM l ) UNKNOWN <br /> III B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l 1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> 'C, ( 1 O1 DOUBLE WALLED t ) 02 SINGLE WALLED l 1 03 LINED <br /> D. ( 1(0; CARBON STEEL l( 1)05O BBROt <br /> 02 STAINLESS <br /> S(E)LI 07ZEFIBERG095COMPOSITE POLYVINYL <br /> IV lOYNON-METALLIC05 CONCRETE <br /> 06 <br /> INUM <br /> LORIDE ( ) <br /> ( 1 12 UNKNOWN ( l 13 OTHER: <br /> _ ( PAGE 1 <br /> H3C04-079185 Z5 <br /> � 1T <br />