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STATE I0 NUMBER <br />APP!Tf`ATTnm FnR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />t ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT t ) 07 TANK CLOSED t ) 09 DELETE FROM FILE (NO FEE) <br />( ) 02 CONDITIONAL PERMIT ( 8 06 AMENDED PERMIT t ) 08 MINOR CHANGE (N0 SURCHARGE) <br />n 1.1 Al C D <br />NAME (CORPORATION, INDIVIDUAL OR PUBLIC AGENCY) FPWLIC AGENCY ONLY <br />) <br />01 FED t ) 02 STAVE t ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />TT CAr'TI TTV <br />FACILITY NAME <br />THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( D INCHES ( ) CM 04 UNKNOWN <br />DEALER/FOREMEN/SUPERVISOR <br />CnJ S7;-t7'f6 Al <br />6 � 7/ <br />t O1 DOUBLE WALLED ( D 02 SINGLE WALLED ( ) 03 LINED <br />STREET ADDRESS <br />( ) 01 CARBON STEEL t ) 02 STAINLESS STEEL tiC( 03 FIBERGLASS ( 8 04 POLYVINYL CHLORIDE ( B 05 CONCRETE <br />NEAREST CROSS STREET <br />CITY <br />COUNTY <br />ZIP <br />S7�� <br />MAILING ADDRESS ;CITY <br />.,� ®„tea a/ <br />STATE <br />c <br />ZIP <br />"r yJ �'3 <br />,f-AIAI4-f3 SV t ra i <br />5 .s-✓ /2 <br />PHONE W/APEA CODE <br />_S S-3�(a <br />TYPE OF BUSINESS <br />t O1 GASOLINE STATION ( B 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP ]RANGE <br />SECTION <br />TTT DG unuo EMERGENCY CnNTACT PERSON <br />DAYS: NAME(•LAST`NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) ANO PHONE W/AREA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (i4- 01 TANK t 1 02 OTHER CONTAINER NUMBER <br />FB.MANUrACTURER (IF APPROPRIATE): ' YEAR MFG: C. YEAR INSTALLED ,, t ) UNKNOWN <br />D. CONTAINER CAPACITY: ' M GALLONS t ) UNKNOWN E. DOES THE -CONTAINER STORE: ( ) 01 WASTE ( ) 02.t.RODUCTr" <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? J74 01 YES t D 02.NO IF YES -CHECK APPROPRIATE BOX(ES): <br />t ) 01 UNLEADED ( ) 02 REGULAR 0 03 PREMIUM ( 104 DIESEL ( B 05 WASTE OIL t ) 06 OTHER <br />nnuTe4sO trn PnklCTDIIPTTnm <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( D INCHES ( ) CM 04 UNKNOWN <br />01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) BMS 02 NON -VAULTED ( ) 03 UNKNOWN _ <br />C. <br />t O1 DOUBLE WALLED ( D 02 SINGLE WALLED ( ) 03 LINED <br />D. <br />( ) 01 CARBON STEEL t ) 02 STAINLESS STEEL tiC( 03 FIBERGLASS ( 8 04 POLYVINYL CHLORIDE ( B 05 CONCRETE <br />( ) 06 ALUMINUM ( ) 07 STEEL CLAD t ) 08 BRONZE t ) 09 COMPOSITE ( ) 10 NON-METALLIC _ <br />4 D 12 UNKNOWN t ) 13 OTHER: <br />---- <br />- t,; 7 --q <br />. HSC04-070185 <br />0 <br />YAb6 1 <br />r nj� <br />yg ap8 f - t? : <br />ENVIR IENTAL HEALTH <br />FERMIT/SERVICES <br />