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e— I <br /> %P <br /> �%Lw <br /> �' / STATE ID NUMBER <br /> APDON FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> lel 01 NEN PERMIT ( 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED l 1 09 OELETC FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME) OPPORATION,IHDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 1 01 FED f 1 02 STATE 1 1 03 LOCAL <br /> STv!!T AC04f5 CITY STATE,. . <br /> v�r! ZIP <br /> �ro <br /> II FACILITY <br /> FAC41TY NAME DEALER/FOREMEN/SUPERVISOR <br /> STREET ADD°ESS NEAREST CROSS STREET <br /> CITY COUNT ZIp <br /> Y MAILING ADDRESS ' `^"r "" f t CITY STATE ZIP <br /> PHONE W'AVEA CODE TYPE OF BUSINESS <br /> 1 ) O1 GASOLINE STATION1 02 OTHER-Mdf7teF(�p�{/[(.jif <br /> NUMBf! CF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM6(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) NO PHONE WIAREA CODE <br /> Ai <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> .A. A. tj 01 TANK f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. TEAR INSTAlLEO ��7CY 1 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: �bALLONS l 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (>kl 02 PRODUCT <br /> F. ODES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOK(ES1: <br /> f 1 01 UILEAOED ( 1 02 REGULAR l 1 03 PREMIUM 66 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t 1 GAUGE ( 1 INCHES 1 ) CH l ) UNKNOWN _ <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNOERGROUM VAULT) '1 1 02 NON-VAULTED ( 1 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE H4LLED 1K1 02 SINGLE WALLED ( 1/03 LINED <br /> D. 1 1 O1 CARBON STEEL 1 1 02 STAINLESS STEEL l�P 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 1 06 ALUMINUM ( ) 07 STEEL CLAD f 1 08 NZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> HiCO4-070185 <br /> L \ �.l <br />