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STATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> l ) O1 NEW PERMIT ( 1 OS RENEWED PERMIT l 1 07 TANK CLOSED <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> PUBLIC AGENCY ONLY <br /> NAME(COP O R ATION.IN IVID L OR PUBLIC AGENCY ( ) 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> ' e rs -ref e <br /> CIT-V STATE <br /> ZIP <br /> STRT ACDgESS IC,-L_�_` Cpm 9 Z3 <br /> II l/FJIACIILITY <br /> DEA R/F OPEMEN/SVPERVISO <br /> FACILITY NAME <br /> e CJ5 <br /> STREET <br /> NEAREST <br /> NEP9E5T CROSS STREET <br /> COUNT <br /> CITY qIs <br /> S <br /> CITY STAT ZIP <br /> MAILI / ODS 5 <br /> refti m <br /> PHONEW/PLEA CODE TYPE OF BUSINESS <br /> _ ^�/ G)Cr01 GASOLINE STATION f 1 02 OTHER <br /> Z7 RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> NUMBER OF CONTAINERS ' <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> D AYS�A IMIL A F RS ) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> / - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (V 01 TANK f ] 02 OTHER: CONTAINER NUMBER 2. <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: ILJ Q'&J GALLONS l 1 UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (Nr 01 YES ( i 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (k1" 01 UNLEADED ( ) 02 REGULAR f ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES ( ) CM (UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Lk-r02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED fxf 02 SINGLE WALLED ( ) 03 LINED <br /> D. 0<f 01 CARBON STEEL ( ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE f ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />