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-� STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 41401 NEW PERMIT f 1 OS RENEWED PERMIT 1 1 07 TANK CLOSED 1 ) 09.OELETE FROM FILE (NO FEE) <br /> 1 1 02 COIIOITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 04 MINOR CHANGE (NO SURCHARGEI <br /> ! OWNER ------- <br /> NAE(000PORATION,INDIVIDU4L OR FUSLIC AOf NCYI ---------__---- ------ -- ---� -- <br /> r. PUBLIC AGENCY ONLY <br /> 1 O1 FED 1 1 02 STATE ( 1 03 LOCAL <br /> STREET ANIRESS <br /> �0 CITY STAT IIP <br /> — -- - <br /> II FACILITY �— <br /> FACILITY NAME OEALER/FOPEMEN/SUPERVISOP <br /> M=KT F►�2n� s P Via,N __ c� �ct3 s til <br /> STFEET ADC-ESS <br /> NEAREST CROSS STREET <br /> G oNmlao L. 7j J <br /> CITY <br /> U ' COUNTY <br /> ZIP <br /> MAILING ADD <br /> IS n I16�41elo CITY STATE LIP <br /> PHONE W•AFEA CODE TYPE OF BUSINESS <br /> _ 6 ( 1 01 GASOLINE STATION ( 1 02 OTHER <br /> NVrISER CF CONTAINERS • PUPAL AREAS ONLY TOWNSHIP — RANGE SECTION <br /> IIT 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NArf(LA(TFNAME FIRSTI A-2&-ND PHONE W/APEA CODE N�N n�[1 � 5fCr IRSTI A��PNONf �A CODE <br /> 11 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 01 TAW f 1 02 OTHER: CONTAINER NUMBER <br /> B_ MANUFACTURER IIF APPROPRIATE)--- --- L1,V1 l/ YEAR MFG__ C. <br /> YEAR INSTALLE`�PP A (` (-1 UNKNOWN - <br /> 0. CONTAINER CAPACITY: 02Q GALLONS I ) UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 HASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAIIIER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> (YJ 01 UNLEADED 1 1 02 REGULAR f 1 03 PREMIUM 1 1 04 DIESEL l 1 OS WASTE OIL 1 ) 06 OTHER <br /> V a CONTAINER CONSTRUCTION <br /> 4. TI!ICPNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 1 IIICHES 1 1 CM 1 1 UNKNOWN <br /> jB. ( 1 01 VAULTED (LOCATED IN AN UNOERGPOUND VAULT 1 1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> JC. 1 1 01 DOUBLE WILLED 0011 02 SINGLE WALLEO ( I 03 LINED <br /> ID. Ik{ 01 CARBON STEEL 1 1 02 STAINLESS STEEL ( 1 03 FIDERGLASS l 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 ✓1�1 06 ALUMINUM 1 1 07 STEEL CLAD f 1 OB BROII2E I 1 09 COMPOSITE 1 1 10 NOH-METALLIC <br /> I 1 12 L"Y'NOWIJ 1 1 13 OTHER: <br /> H5[04-0,-^IDS <br /> PAGE <br />