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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> T 1 02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT 1 1 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATIO INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) <br /> 01 FED f l 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> lL G <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> STREET ADOPESS� q�( NEAREST CROSS STPECT <br /> [ G/ <br /> CITY COUNTY ZIP <br /> MAILING ADDRESS CITY STATE ZIP <br /> a7 M24" <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> ( ) <br /> 01 GASOLINE STATION 1 02 OTHER <br /> NUMBER OF CONTAINERS RVRAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMC(IPST NAME FIRST) AND PRONE W/AREA eooe <br /> 17,91, 4QU �oTrZ7 S _ po/f7� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (y 01 TANK [ ) 02 OTHER: CONTAINER NUMBER 7 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> O. CONTAINER CAPACITY: 9P0,00GALLONS l ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE l 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? �01 YES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 01 UNLEADED f ) 02 REGULAR f ) 03 PREMIUM ) 04 DIE 1 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE f l INCHES ( ) CM ( UNKNOWN <br /> S. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. �( )) 01 DOUBLE WALLED 02 SINGLE WALLED ( ) 03 LINED <br /> D. iX, 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD l 1 08 BRONZE f l 09 COMPOSITE f ) 10 NON-METALLIC <br /> l ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE I <br />