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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( NEW PERMIT ( 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09 OELETE' FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I 01•I N E R <br /> NAME(COPoORF.-i"4104uz— T PUBLIC AGENCY ONLY <br /> 1 01 FED l 1 02 STATE t 1 03 LOCAL <br /> STc_ET ACORESS L� S t CITY S -- STATE--- ZIPq,66 7- <br /> L <br /> 5�4 <br /> II FACILITY <br /> 5a <br /> FACILITY NAME l EALER CPEMEN/SUPERVISOP <br /> STFEET ACV'ESS NE ST 6 OSS ST PEE / <br /> CITYa / — COUNTY ZIP <br /> 1 MAILING ADOPESS CITY STATE_ <br /> PHONE W•'APEA CODE TYPE OF BUSINESS <br /> SOL NE STATION ( ) 02 OTHER <br /> � _ G <br /> NUMBER CF CONTAINERS DURAL AREAS ONLY TOWNSHIP PANGE SECTION <br /> 3 - <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> EDAYS: NAME LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> — — =!3�6 9 <br /> _ <br /> 7S7 <br /> HE FOLLOWING ON A SERAT <br /> IV DESCRIPTION —_-- <br /> A. ( 0 ANK ( 1 02 OTHER: CONTAINER NUMBER T_ <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED� 1 UNKNOWN_ <br /> D. CONTAINER CAPACITY: 12GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE. ( ) 01 WASTE (")4-02 PRODUCT — <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 5 ( 1 02 NO IF YES CHECK APPROPRIATE BOXIEST <br /> ( ) 01 UNLEADED ( 0 EGULAR t ) 03 PREMIUM ( ) 04 DIESTL ( ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: Ll�/� ( ) GAUGE ( ) INCHES ( 1 CM ( ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNOERGROUNO VAULT) (4 0 -VAULTED ( ) 03 UNKNOWN <br /> �C. O1�OY-60UBLE W1LLEO ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL 6 E R G L A 5 S ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM l 1 07 STEEL CLAD ( 108 RONZE l ) 09 COMPOSITE ( ! 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: —_ <br /> PAGE 1 <br /> HSC04-0 0185 <br />