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NATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT 4 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> Ai"E(CORaORATION.INQIVIQUkL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> �1�N V-05, <br /> 5! ��iJ ( ) O1 FED ( l 02 STATE ( 1 03 LOCAL <br /> 4 <br /> Cl <br /> Ej <br /> ET ACr)R SS CITY STATE ZIP <br /> :TP <br /> -7 �O M i 1�► r� r� Uc: 7v CE r�:z U <br /> I FACILITY <br /> AGILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> C �A ft 1� OS '"�� (?.- C HA r <br /> STREET <D 'ESS NEAREST CROSS STREET <br /> CITY / :C10 ` l/ ZIP UN7Y ✓\ w t y i R I /V <br /> MAILING ADDPE55 CITY fv STATE ZIP <br /> PHONE WiAtEA COD TYPE OF BUSINESS <br /> / (,�) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF CONTAINERS RUP.AL AREAS ONLY TOWNSHIP PANGS SECTION <br /> II 24 HOUR EMERGENCY CONTACT PERSON <br /> AYS: NAME9 �AST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME{LAS NAME FIRST) AND PHONE W/AREA CODE <br /> C dA 4j XelS5S <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> V DESCRIPTION <br /> (>1 01 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLEQ_jaJ_6( 1 UNKNOWN <br /> J. CONTAINER CAPACITY: 2fq GALLONS ( 1 UNKNOWN E. ORES THE CONTAINER STORE ( 1 01 WASTE t ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXES) <br /> 1 1 01 UNLEADED ( 1 02 REGULAR f ) 03 PREMIUM ( ) 04 DIESEL ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE [ ) INCHES ( ) CM _�7x UNKNOWN <br /> E. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( 03 UNKNOWN <br /> 01 DOUBLE W%LLED 02 SINGLE WALLED ( ) 03 LINED <br /> jG. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> i� �f 1 06 ALUMINUM ! 1 07 STEEL CLAD ( 1 08 BRONZE 1 ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> Sr04-070185 <br />