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STATE ID NUMBER <br /> OPERATE UNDERGROUND STORAGE TANK <br /> APPLICATION FOR PERMIT TO w—_ <br /> _ --------- -- --- --�� ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 05 RENEWED PERMIT 1 1 07 TANK CLOSED <br /> � O1 NEW PERMIT <br /> 1 p2 CONDITIONAL PERMIT _ 1`1 06 AMENDED PERMIT _l ) 0$ MINOR CHANGE tNO SURCHARGEI <br /> I OWNER PUBLIC AGENCY ONLY <br /> -- _ i 1 OL FED I 1 02 STATE 1 1 03 LOCAL <br /> —F pPORFTION.INDIVIDU&L OR PUBLIC AGENCY) <br /> N4Y._(CO ..--- - -- <br /> CITY STATE <br /> STCEET AO"ESS <br /> �3 ' f [i✓lf� �`�'J .�____�._ <br /> II FACILITY I LER/FOPEMENVSUPEPVISOR <br /> FACILITY N4NE -- – .— REST CROSS STPEET <br /> LCOES � ZIP <br /> L _ NTY <br /> CITY 'lL/1/J] ---- <br /> __. STATE ZIP <br /> CITY <br /> MAILING ADOPESS -- <br /> Pr'ON`_ W'A°EA CODE' TYPE CF BUSINESS <br /> 02 OTHER <br /> Gr GQ 0�— c 1 01 GASOLINESTATIONl- 1 JPsr1GE SECTION <br /> NUr'BER CF CONTAINER PUPAL AREAS ONLY T4WNS++IP �— — <br /> III 2e1 HOUR EMERGENCY CONTACT PERSON — — — <br /> DAYS: NIGHTS: HAME(lAS7 NAME FIRST)_AND'PHONE W/APEA CODE <br /> NAmEtIAST NAME FIRST) AND PHONE N/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION -- — <br /> A. ( 01 TAttK t ) 02 OTHER' CONTAINER NUMBER <br /> YEAR MFG: C. YEAR INSTALLED (x) UNKNOWN <br /> B. MANUFACTUP.ER (IF APPROPRIATE) - <br /> 0. CONTAINER CAPACITY: Gr U-li"D GALLONS [ 1 UNKNOWti E. OOES THE CONTAINER STORE:--I 1 O1^WASTE l ) 02 PRODUCT <br /> F ODES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES I 1 02 NO IF YES CHECK APPROPRIATE BOKlE51: <br /> 1-1 <br /> 01 UttLEADED 1�4 02 REGULAR- ( 1 03 PREMIUM-- I 1 04 DIESEL 1 1_05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. fiHICKIIFSS OF PRIMARY CONTAINMENT: ( ! GAUGE l 1 INCHES 1 1 CM [ 1 UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNOERGROUND VAULT) l�i 02 NON-VAULTED E 103 UNKNOWN _- — <br /> IC. t 1 01 DOUBLE WALLED (A) 02 SINGLE WALLED i 1 03 LINED — <br /> fD. (x) 01 CARBON STEEL [ ) 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> fl I 1 06 ALUMINUM f ) 07 STEEL CLAD ( 1 08 BRONZE f 1 09 COMPOSITE l ) 10 NON-METALLIC <br /> i ) 12 UNKNOWt1 ( 1 13 OTHER: <br /> PAGE 1 <br /> L� V <br />