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STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />t ) <br />01 NEW PERMIT ( ) 05 RENEWED PERMIT t ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />t ) 02 CONDITIONAL PERMIT t 8 06 AMENDED PERMIT t ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME (COP PORATION.%NDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />I OE STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />; S ''/ /tA`o A✓ C <br />TT F®CTITTV <br />FACILITY NAME <br />B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: <br />DEALER/FOREMEN/SUPERVISOR <br />C /`iFv,e-d /✓ S7, -o 1'6 Al <br />& i 7/ <br />E. DOES THE'CONTAINER STORE: t <br />STREET ADDRESS <br />6 G_ �� �-! �! c- <br />-cls. <br />NEAREST CROSS STREET <br />/FE 114- <br />(tiCITY <br />_ <br />CITY <br />S C -4 --Ta A--' <br />COUNTY <br />S�1 a/ ae � � � �✓ <br />ZIP <br />? r --a 7 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />/f- AI AI f{3 •EL L .✓- S Ll c r-99;7 i <br />. Sd.✓ /Z ..� oma �t / <br />� <br />C'/ -vi-o; -3 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />� -S S-3 �-�® <br />(X 01 GASOLINE STATION t ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />aperY x/77 -1,1/1f- 01LC- <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />III nrcrDTPTTnN <br />A. 04 01 TANK ( A 02 OTHER: CONTAINER NUMBER <br />B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: <br />C. <br />YEAR INSTALLED t ) UNKNOWN <br />D. CONTAINER CAPACITY: GALLONS t ) UNKNOWN <br />E. DOES THE'CONTAINER STORE: t <br />) 01 WASTE t ) 02.�,RODUCT,," <br />f. GOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? P4. 01 YES t ) 02,NO <br />( ) O1 UNLEADED t 1 02 REGULAR ( 1 03 PREMIUM t ) 04 DIESEL t ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES)" i <br />t D 06 OTHER <br />v rnaTAym=v rnNCTR))rTTnN <br />A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE t ) INCHES ( ) CM 04 UNKNOWN <br />B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 04 02 NON -VAULTED t ) 03 UNKNOWN <br />C. (X 01 DOUBLE WALLED ( ) 02 SINGLE WALLED .t ) 03 LINED <br />D. ( 1 01 CARBON STEEL t ) 02 STAINLESS STEEL 04 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE t ) 05 CONCRETE <br />( ) 06 ALUMINUM t ) 07 STEEL CLAD t ) 08 BRONZE ( ) 09 COMPOSITE t -�u r` <br />( ) 12 UNKNOWN t ) 13 OTHER: <br />HSC04-070185 <br />• <br />Ll ( PAGE 1 <br />*J <br />J A N1 I'EN <br />Vi O ENTAL HEALTH <br />FERMIT/SERVICES <br />