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STATE ID NUMBER <br />&PP)TrATTnm FnR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />( ) <br />01 NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED t D 09 DELETE FROM FILE (NO FEE) <br />t D 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGED <br />NAMEtCOPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />01 FED ( D 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />__a2 �,vNsn3f e- L Af . Srl A/ ,fAIla i✓ <br />v t CA r T I T TV <br />FACILITY NAME <br />DEALER/FOREMEN/SUPERVISOR <br />(5 AJ X 7:.It776 Al <br />6171 <br />C' <br />STREET ADDRESS <br />z C.. <br />rl <br />NEAREST CROSS STREET <br />/3 E1/ -7-A 141 ( W l -)r d e -l' t <br />CITY <br />( ) 12 UNKNOWN t ) 13 OTHER: <br />COUNTY <br />s4 0 � v o9 c� u <br />ZIP <br />MAILING ADDRESS <br />CITYSTATE <br />-r-✓ ra awo A -1c <br />ZIP <br />�/ y✓�o ° 3 <br />,y-A.1Al&a a-� L .✓_ SV t T� � <br />S Ie <br />PHONE W/AREA CODE <br />_1 S -3S` CTU® <br />TYPE OF BUSINESS <br />(`X 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERSRURAL <br />AREAS ONLY TOWNSHIP <br />RANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: HAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />71 LC <br />617 2 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />Tv nrcrRTPTTnm <br />n na�Ta lacca rnAPC T Q)1rT T nm <br />A. THICKNESS OF PRIMARY CONTAINMENT: ( D GAUGE t ) INCHES ( ) CM 04 UNKNOWN <br />01 VAULTED (LOCATED IN AN UNDERGROUND VAULTI (k4 02 NON -VAULTED t ) 03 UNKNOWN <br />C. (X 01 DOUBLE WALLED t ) 02 SINGLE WALLED ( ) 03 LINED <br />D. t ) 01 CARBON STEEL t D 02 STAINLESS STEEL (N 03 FIBERGLASS t 1 04 POLYVINYL CHLORIDE t <br />) 05 CONCRETE <br />t D 06 ALUMINUM ( ) 07 STEEL CLAD ( D 06 BRONZE t ) 09 COMPOSITE t ) 10 NON-METALLIC <br />( ) 12 UNKNOWN t ) 13 OTHER: <br />HSC04-070185 <br />NVIRC 4E„ TA! HEALTH <br />ERIIT/SERVICE <br />