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STATE ID NUMBER <br /> E TANK <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND�a GDEtE7E FROM FILE (NO FEE) <br /> ( } 47 TANK CLOSED <br /> O1 NEW PERMIT. ( ) 05 RE`EWLO PERMIT ( ] OS MINOR CHANGE (NO SURCHARGE) _ <br /> 02 CONDITIONAL PERMIT <br /> E ] 06 AmuoED PERMIT <br /> [�) Q ya N F R --- -� -- PUBLIC AGENCY ONLY <br /> -� <br /> PUBLIC 41 FED ( 3 02 STATE L(OGALNAMEECRPORATICN INDI'v'IDl1AL DR Pl1BlIC AGENCY) STA /';CSE �1J <br /> STREET�PES-SN, <br /> II FACILITY _ � DEAI.ER/FOREMAN/SUPERVISOR S <br /> celnN CX <br /> FAITY NAI" S,1 <br /> (j Lf NEAREST CROSS ST EET <br /> STREET ADDRESS wVPh c `T— ZIP = <br /> QI ri COUNTY �� ti -J <br /> f <br /> YTY �]L STATE ZIP��� <br /> ! Q _ CITY �j <br /> MAILING ADDRESS <br /> TYPE OF BUSINEss } D2 OTHER <br /> PKONE <br /> �W/AREACODE ( ) O1 GASt]IINE STATION SECTION <br /> 200j` && —�_a RANGE <br /> RURAL AREAS ONLY TOWNSHIP <br /> NUMBER OF CONTAINERS <br /> iII 24 HOUR EMERGENCY CONTACT PERSON NIGHT NAMEtLAST NAME FIRST) AND`PHONE W/AREA CODE <br /> DA'I'S: NA,ME(LAST NAME FIRST) AND PHONE W/A4)EA 'ODEcke [/ �1/ <br /> ~ C� <br /> EACH CONTAINER <br /> COMPLETE SHE <br /> FOLLOWING ON A SEPARATE FORM FOR EA------_--- <br /> I V DESCRIPTION <br /> CONTAINER NUMBER <br /> A. (+» O1 TANK ( ) 04 OTHER. UNKNOWN <br /> YEAR MFG; C. YEAR INSTALLED _L cul <br /> FACTURER tIF APPROPRIATE)- l 2 PRODUCT----- <br /> -�� GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) OI WASTE ( <br /> AINER CAPACITY 6 _-- ,' E)C1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES). <br /> D. C -- �� <br /> p4 DIESEL ( ) 05 WASTE OIL { ) 06 OTHER <br /> F. THE CONTAINER STORE MOTOR VEt(ICLI� FUEL OR WASTE OIL <br /> ( ) O1 UNLEADED ( 3 02 REGULAR ( ) 03 PREMIUM ( ) <br /> V CONTAINER CONSTRUCTION <br /> ( ) GAUGE ( ) INCHES ( ) CM i UNKNIIWN - <br /> A. THICKNESS OF PRIMARY CONTAINMENT: <br /> NON-VAULTED 03 UNKNOWN <br /> B. <br /> } VAULTED TED IN AN UNDERGROUND VAULT) ( 02 t ) <br /> C ( } O1 Ot)UBL1 <br /> E WALLEO t D2 SINGLE WALLED ( ) 03 LINED i ) 09 COMP05I7'E ( ) 0 NON-METALLIC <br /> , ON STEEL t ) 02 STAINLESS 08 <br /> [ ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE 4 ) 05 CONCRETE <br /> D. CARE <br /> { ) 06 ALUMINUM I ) 07 STEEL CLAD ( ) 08BRONZE —�-� PAGE <br /> ( ) 12 UNKNOWN E ) 13 OTHER: <br /> HSC04-070185 <br />