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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> lX- 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> Ti 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OONER <br /> NAMORPORATICN,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> A S • ( ) 01 FED ( l 02 STATE ( l 03 LOCAL <br /> STREET ADDRESS /o _ j)0 V F_94AL Lr r /�/ PcAZ.4 CITY UNJ I v6V--,A .. C11-1 STATE ZIP gJ60F <br /> /D. a• • U 370.6 cry <br /> II FACILITY <br /> PACILZTY NAME DEAL/E1R/FOREMAN/SUPERVISOR <br /> STREET ADDRESS NEAREST CROSS STREET <br /> Hy w (51 z4mcoavl <br /> CITY 1 COUNTY ZIP t <br /> S i CSL Jz; �Q J (A <br /> IC/ v C.)o <br /> MAILING ADDRESS CITY <br /> JSTE ZIP <br /> ^1yU w . ChccnTn 2, w 3Jr,-k�� � 9�36 (o <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> v9 q( ()() 01 GASOLINE STATION ( ) OZ OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE /I SECTION <br /> III 24 FLOUR 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 /> !Er!Aco Cks1�rn�2 <br /> 561C ,L0 aA;411. NQiKh 17F)U GI(o - b-37% a <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 1,01 TANK ( l 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): XE XXES YEAR MFG: 81f C. YEAR INSTALLED ( ) UNKNOWN <br /> lZ( <br /> D. CONTAINER CAPACITY: 000 GALLONS ( ) UNKNOWN JE. DOES THE CONTAINER STORE: ( l 01 WASTE (X2 02 PRODUCT <br /> F. QOfS THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? GN 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (X) 01 UNLEADED ( ) 02 REGULAR 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( ) INCHES ( ) CM A\) UNKNOWN <br /> S. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) J( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 2S,DZ SINGLE WALLED ( ) 03 LINED <br /> D. 01 CARBON STEEL ( ) OZ STAINLESS STEEL JX) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CO)ICRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE l ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN 1 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />