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y.. STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 01 NEW PERKIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 DELETE FROM FILE (NO FEET <br /> Trl 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NA (CORP ORATION.INOIVIpp&L OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Y.E <br /> 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br /> CIT STATE ZIP <br /> STREET ACn S <br /> II FACILITY <br /> FACZL TY NA-,E OE4LE R/F_ OREMENIS PEPVI/SO R-'/C <br /> STREET ADDIESS NEAPES CROSS STREET <br /> CITY COUNT ZIP <br /> !jl MAILING PCD Pf SS CITY STAT! ZIP <br /> PHONE W MFE• CODE TYPE OF BUSINESS C LLgq L <br /> _OYR 'l 1 001 GASOLINE STATION 1 _02 OTHER <br /> NUMBER /CFPCONTAZNEPS RVR AL AREAS ONLY TOWNSHIP RANGE SlCTZON <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DA S: NAM,E(LA T NAME FIPST) 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. (I) 01 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 5M GALLONS 1 1 UNKNOW)) E. DOES THE CONTAINER STORE: ( 1 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 4('1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED ( 1 02 REGULAR ( 7 03 PREMIUM l 1 04 DIESEL l ) 05 WASTE OIL l 1 06 OTHER___ <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE f 1 INCHES ( ) CM (Y,) UNKNOWN _ <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (IL) 02 MON-VAULTED 1 ) 03 UNKNOWN <br /> IC, 1 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED 1 1 03 LINED <br /> D. 1 1 01 CARBON STEEL l 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM 1 ) 07 STEEL CLAD 1 1 08 BRONZE 1 ) 09 COMPOSITE l ) 10 NON-METALLIC <br /> (\j 12 UNKNOWN l 1 13 OTHER: <br /> HSC04-07D185 PAGE 1 <br /> JLC �i <br />