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STATE mNUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK � <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> GI NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> 02 CONDITIONAL PERMIT 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OPINE <br /> PUBLIC AGENCY ONLY <br /> NAME(COPPORATION,INDIVIOU4L OR PUBLIC AGENCY) <br /> 010 01 FED 02 STATE 03 LOCAL <br /> STATE ZIP <br /> STREET ADDRESS <br /> t-f-k�-o T�_T9"_3 <br /> -ECI T Y <br /> II FACILITY <br /> FACILITY NAME' <br /> STREET fDDPE�� NEAREST CROSS STREET <br /> r.1)11�11 T Y"_ ZIP <br /> CITY 51 <br /> i_� CITY ST&TE ZIP <br /> MAIL ADDRESS La�)krop <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> RANGE SECTION <br /> NUMBER OF CONTAINERS PUPAL AREAS ONL <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> /AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W <br /> F�_ --- <br /> COMPLETE THE FOLLOWING ON 4 SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> CONTAINER NUMBER 15-3 <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLED (,VrUWNOWN <br /> 0. CONTAINER CAPACITY: 113:5— GALLONS UNKNOWN E. DOES THE CONTAINER STORE: 01 WASTE ()<ro2 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL (kr 01 YES 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 01 UNLEADED 02 REGULAR 03 PREMIUM OKI 04 DIESEL 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM (V UNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) '*-, ) 02 NON-VAULTED ( ) 03 UNKNOWN- <br /> C. ol DOUBLE WALLED (A 02 SINGLE WALLED 03 LINED <br /> D. 01 CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> ) 06 ALUMINUM 07 STEEL CLAD 08 BRONZE 09 COMPOSITE 10 NON-METALLIC <br /> 12 UNKNOWN 13 OTHER: <br /> PAGE 1 <br /> � osc0*-0701e5 <br /> / <br /> _ _, <br />