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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( t1 NEW PERMIT ( 1 05 RENEWED PERMIT 1 ) 07 TANK CLOSED ( 7 09 DELETE FROH FILE (NO FEET <br /> o CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT f ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMELGpRPORATION, NDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 1( ) 01 FED 1 ) 02 STATE f 1 03 LOCAL <br /> STREET ADDRESS CITY- STATE ZIP <br /> I <br /> CAL <br /> II FACILITY <br /> FACILITY NAME DEALER/FOAE N/SVPEPVISOR <br /> RE i5 <br /> STREET FDD?ESS NEAREST CROSS STREET <br /> CITY COUNT ZIP <br /> G/ <br /> MAILING ADOPESS� (� CITY STATE ZIP_ <br /> PHONE W%APEA CODE TYPE OF BUSIN SS Q <br /> 01 GASOLINE STATION f 02 OTHER <br /> NUMBER OF CONTAINEPS RVR At AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NA�Mj,E(�LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: 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. ((,l 01 TANK ( l 02 OTHER: CONTAINER NUMBER <br /> S. MANUFACTURER (IF APPROPRIATE): YEAR MFG= C. YEAR INSTALLED ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: tfiaGALLONS ( 1 UNKNOWN I E. DOES THE CONTAINER STORE: ( 1 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? P- 01 YES Q D2 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( . 1 05-WASTE OIL !&-06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( ) 03 LINED <br /> D. (01 CARBON STEEL ( l 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD l ) 08 BRONZE 1109 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070183 PAGE 1 <br />