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..i <br /> • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( „01 NEW PERHIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I <br /> 064NER <br /> —— PUBLIC AGENCY ONLY <br /> NAMrP ORATIO INDI AL OR PUBLIC AGENCY) ( ) 01 FED l 1 02 STATE q�3 LOCAL <br /> l/E'L ` <br /> STATE ZIP <br /> srcEE32 s <br /> R�-s <br /> II FACILITY h <br /> DE LEP/FOREMAN/ U ERVIS R p <br /> FACT ITY NAM Yip <br /> d <br /> NEAREST CP SS STREET <br /> STREET ADDRESS !� <br /> SSU <br /> C05TY 1 <br /> DUTY C.0-c J0^ � <br /> ZIP <br /> �.MAILI AOOPE55 CITY STATE <br /> ` 1 <br /> PHONE W/AREA CODE TYPE OF BUSINESS I - ll <br /> 0 _ ( 1 01 GASOLINE STATION L�02 OTHER L.LIML 111 <br /> NUMBER OF`CONTAINERS RURAL AREAS ONLY TOWNSHIP <br /> RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS' NAME(LA T AME FIRST) AND PHONE W/AREA CODE NI TS:/NA E(IAST NAME FIRST) AND PHONE W/AREA CODE <br /> e 3 y s ler X09- $ -¢s <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. Oer-01 TANK ( 1 04 OTHER: CONTAINER NUMBER _A9_z_ <br /> B. MANUFACTURER IIF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED a.r�.�NOWN <br /> D. CONTAINER CAPACITY: /5-90 ALLONS ( 1 UNKNOWN! E. DOES THE CONTAINER STORE: l 1 01 WASTE ( 2 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE 1L ? LjdHEal YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> l ) 01 UNLEADED l ) 02 REGULAR ( 1 03 PREMIUM (QCT 04 DIESEL [ ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) ,GAAUGE ( l INCHES ( ) CM LUAU KNOWN <br /> (Y1 <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> C. l 1 01 DOUBLE WALLED (41�02 SINGLE WALLED ( ) 03 LINED <br /> 0. t ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL 1 ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD 1 ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 12 lR0(NJOWN 1 ) 13 OTHER: _ <br /> HSC04-070185 PAGE 1 <br /> 1 � �� <br />