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y STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ll��1 <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT t ) 06 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.2 NOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 11 ( ) 01 FED f ) 02 STATE f ) 03 LOCAL <br /> STREET ACORlSS CITYSTATS LIP <br /> II FACILITY <br /> FACILITY NAA DEALE FORlMlN/S ERVISOR <br /> STREET ADD,E SS NEAREST -CROSS STREET <br /> 8 W <br /> CITY COUNT ZIP r <br /> MAILI"lAODPES CITY STATE ZIP <br /> D-0© <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> QQt_ l 1 01 GASOLINE STATION ( ) 02 OTHER 5 T L <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE + SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> a YS: NAM,!(LAST''J'�N�AME FIRST) AND PHONE W/ARCA CO21,04 NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> (btr(a&k ,- .at!Wi ( -7e13-�nt� , X7fDE 411�7Clfl�A�(QlAltc i� �7G� X7-1ZS <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (�) 01 TANK ( ) 02 OTHER: CONTAINER NUMBER / <br /> B. MANUFACTURER (IF APPROPRIATE): - YEAR MFG: C. YEAR INSTALLED f UNKNOWN <br /> D. CONTAINER CAPACITY: ZaA;--Z GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 01 YES 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 01 UNLEADED ( ) 02 REGULAR 1 ) 03 PREMIUM (' 1 04 OIESEC t 1 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( ) INCHES ( 1 CM (w UNKNOWN <br /> B. ( ) 01 VAULTED ILOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED 1 1 03 LINED <br /> D. 1`%, O1 CARBON STEEL l ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS 1 ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM i ) 07 STEEL CLAD ( ) 08 BRONZE l ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />