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IW STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> !y) 01 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> I' 1 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) OS MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> MAME(C PPORATION.IHDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> O ( ) <br /> 01 FED ( ) 02 STATE l ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 0 5roa�rv,E' C <br /> •----� <br /> II FACILITY <br /> FACILITY "AMI. OEALER/FOREMEN/SUPERVISOR <br /> p <br /> STREET <br /> ADO?ESS NlARlST C4055 STREET <br /> 0 l <br /> CITY COUNTY ZIPlitk <br /> �� <br /> MAILING ADDPE 5 CITY ' STAT!_ ZI <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> ( ) 01 GASOLINE STATION O0 02 OTHER *c <br /> "ER OF CONTAINERS RVRAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME) ST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE WIAREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 01 TAMC ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED l ) UNKNOWN <br /> D. CONTAINER CAPACITY:(O GALLONS ( 1 UNKNOWN I E. DOES THE CONTAINER STORE: ( ) 01 WASTE f 7 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( r`L 01 YES Oer 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM I, .I 04 DIESEL ( ) 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: [ ) GAUGE ( 1 INCHES ( ) CM jai UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) i*02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 O1 DOUBLE WALLED ( 1 02 SINGLE WALLED f ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL 4KL03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM ( ) 07 STEEL CLAD ( l 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> l 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> �l4J <br />