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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> _ 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENn ED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I DONE <br /> NAhE(CORPORATICN,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> _ S ( ) 01 FED ( ) 02 STATE ( 1 03 /LOCAL <br /> STREET ADDRESS 10 L)N I Vf_e5A(_ (:(T-Y CITY tiN�d&12S�4L C lrY STATE ZIP 9l(00(3 <br /> T. 0. 804 3`?O-� cfq <br /> II FACILITY <br /> PACILITY NAM! DEALER/FOREMAN/SUPERVISOR <br /> �- <br /> STREET ADDRESS NEAREST CROSS STREET <br /> '`I`I w C}iwlt ,, 6o,(Cc fS� <br /> CITY 11 1_ COUNTY" ZIP <br /> MAILING ADDRESS CITY STATE ZIP <br /> ^1yy w _ Lhcun�Q, w S-��kw� e� v�ao (D <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION ( l 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLYTOWNSHIP RANGE SECTION <br /> 7�71 III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAPS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> EYAco Cks'�orn�2 S�� ;�� CEA;-ez „uQicl� CAU; G►ca — `i -31>o <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (I,01 TANK ( ) 04 OTHER: CONTAINER NUMBER <br /> �cer2x�s /Iffy <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED. ( ) UNKNOWN <br /> D. CONTAINER CAPACIT� 0() GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (,'IQ 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (N 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (�) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM A"\1 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) J( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. f 1 01 DOUBLE WALLED ( n,02 SINGLE WALLED l ) 03 LINED <br /> 0. 01 CARBON STEEL ( ) 02 STAINLESS STEEL 03 FIBERGLASS l ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM 1 ) 07 STEEL CLAD l ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN f 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />