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STATE IO NUMBER <br />APP(TCATT(1N FOR PFRMIT TO OPERATE UNDERGROUND STORAGE TANK <br />( D OI NEW PERMIT ( D OS RENEWED PERMIT ( ) 07 TANK CLOSED t 1 09 DELETE FROM FILE (NO FEE) <br />( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) OS MINOR CHANGE (NO SURCHARGE) <br />ni.ifJCO <br />NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY <br />FED ONLY <br />OE STATE ( ) 03 LOCAL <br />STREET ADDRESS CYTY STATE IF <br />_�2� NN�4f L c Al . c Sr9 Al /�Mo �✓ <br />II FACILITY <br />FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br />I . i . 77 . <br />TTT 24 HOUR FMFRPFNCV CONTACT PERSON <br />�DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE - NIGHTS: HAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />ic cr_ - - acry c/ 7 2_yeas' I71LC— <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (i4.01 TANK t ) 02 OTHER: CONTAINER NUMBER <br />X <br />YEAR MFG= 7 C. YEAR INSTALLED ( ) UNKNOWN <br />B. MANUFACTURER (IF APPROPRIATE): f <br />D. CONTAINER CAPACITY: 0 /4 GALLONS ( D UNKNOWN JE. DOES THE'CONTAINER STORE: ( ) 01 WASTE ( 1 02.�RODUCT <br />F. HOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES ( ) 02.N0 IF YES CHECK APPROPRIATE BOX(ES1: <br />01 UNLEADED t ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( J 06 OTHER <br />. •. rn nnL.&'P011rTTnee <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE t ) INCHES ( <br />STREET ADDRESS ® <br />NEAREST CROSS STREET <br />�E�% lid t`%G 7 - <br />(o �_ ! �$ C (�/ C.. <br />_Yf�-. fM- ( !✓ <br />_ <br />CITY <br />COUNTY <br />ZIP <br />S7D C-1,7-0 /J <br />J'40 <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />MAILING ADDRESS <br />CITY <br />a/ <br />STATE <br />C <br />ZIP <br />�'rY✓ m'3 <br />,g-AlAl-4-a .0- e- . � .✓. SUt 7-42rY i <br />-C <br />Sd�✓ <br />-- - <br />0117 .' l III I <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />_S �31f=�-�® <br />(X 01 GASOLINE STATION t ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />----f— <br />TTT 24 HOUR FMFRPFNCV CONTACT PERSON <br />�DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE - NIGHTS: HAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />ic cr_ - - acry c/ 7 2_yeas' I71LC— <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (i4.01 TANK t ) 02 OTHER: CONTAINER NUMBER <br />X <br />YEAR MFG= 7 C. YEAR INSTALLED ( ) UNKNOWN <br />B. MANUFACTURER (IF APPROPRIATE): f <br />D. CONTAINER CAPACITY: 0 /4 GALLONS ( D UNKNOWN JE. DOES THE'CONTAINER STORE: ( ) 01 WASTE ( 1 02.�RODUCT <br />F. HOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES ( ) 02.N0 IF YES CHECK APPROPRIATE BOX(ES1: <br />01 UNLEADED t ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( J 06 OTHER <br />. •. rn nnL.&'P011rTTnee <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE t ) INCHES ( <br />D CM 04 UNKNOWN <br />B. <br />( D O1 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ()4 02 NON -VAULTED 4 <br />1 03 UNKNOWN - <br />C. <br />(X 01 DOUBLE WALLED ( D 02 SINGLE WALLED ( ) 03 LINED <br />D. <br />( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL (>q 03 FIBERGLASS t ) 04 <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 06 ALUMINUM ( J 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE <br />( ) 10 NON-METALLIC <br />( ) 12 UNKNOWN ( D 13 OTHER: <br />- <br />-- - <br />0117 .' l III I <br />HSC04-070185 <br />10 <br />E VIROMENTAL HEAL <br />FERMIT/ E VIC S <br />