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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME( PPOR AT ION. ND IVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> l ) <br /> 01 FED 1 1 02 STATE ( ) 03 LOCAL <br /> STREET ACORESS ` CITY STATE ZIP <br /> II FACILITY <br /> FACILITY�14ME DEALER/FOPEMEN/SUPERVISOR <br /> STPEET ADC?ESS NEAREST CROSS STREET <br /> I? q <br /> dagz, <br /> CITY COUNT ZIP <br /> IZ <br /> l X37 <br /> MAILING ADDRESS /�( CITYSTATEZIP <br /> PHONE W/APER CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION 02 OTHER <br /> NUMBER OF CONTAINER 5_ <br /> RVR AI AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,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. 14601 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: ej62aQ. GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: f ] 01 WASTE ;4 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? olyrol YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 ) <br /> 01 UNLEADED ( l 02 REGULAR ( 1 03 PREMIUM 04 DIE ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: l ) GAUGE ( ) INCHES ( ) CM2:::) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED l ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. 1 1 O1 CARBON STEEL t 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) OS CONCRETE <br /> 1 06 ALUMINUM l 1 07 STEEL CLAD ( ) OB BRONZE f 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( 1 13 OTHER: <br /> . HSC04-070185 PAGE 1 <br />