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1Z�(iM7 o V� <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT R TE UNDERGROUND STORAGE TANK <br /> fXl <br /> 01 NEW PERMIT l ) 05 RENEWED PERMIT Q/1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> TT 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT (� 1 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP PORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED f ) 02 STATE f ) 03 LOCAL <br /> STREET ACCRESS CITY STA T,E� ZIP <br /> CITs <br /> II FACILITY <br /> FACILI Y NAM DEAL R/FOP MENISUPERVISOP <br /> Ot,T _ � <br /> STREET AOD°ESS NEAREST CROSS STREET <br /> CITY ��� COV NTy� ZIP <br /> MAILING ADOP S CITY STATE ZIP <br /> o Cry ? <br /> HONE W!AFEA CODE TYPEOF BUSINESS <br /> ( ) 01 GASOLINE STATION (L) 02 OTHER Qlta*par- <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM.Et LAST NAME FIPST) AND PHONE W/AREA CODENIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( ) 01 TANK f ) 02 OTHER: CONTAINER NUMBER 17 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (j ) UNKNOWN <br /> D. CONTAINER CAPACITY: Mo GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE ( 7 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL DR WASTE OIL ? f 1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> ( ) 01 UNLEADED l 1 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ] 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( 1 INCHES ( ) CM (1,6 UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED f 1 03 UNKNOWN <br /> rIC. ( 11 O1 DOUBLE WALLED ( 1 02 SINGLE WALLED l ) 03 LINED <br /> ID. Ly7 O1 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ALUMINUM ( ) 07 STEEL CLAD f 1 08 BRONZE ( 1 09 COMPOSITE f 1 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( 1 13 OTHER: <br /> H5C04-070185 PAGE I <br />