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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> �C1 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEET <br /> ( 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMECOPPORA�N.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( 1 01 FED f 1 02 STATE l l 03 LOCAL <br /> STREET AC qR S CST STATE ZIP <br /> /lJ <br /> II FACILITY <br /> FACILITY NAME DEALER/FCREMEN/SUP ERVISOP <br /> STREET ADD?ESS NEAREST CROSS STREET <br /> CITY COUNTY ZIP <br /> MAI)ING AODPESS CITY STATE ZIP <br /> �$ 1L ( 5 <br /> PHONE W�A�EA LODE TYPE OF BUSINESS <br /> - f l <br /> 01 GASOLINE STATION (4f 02 OTHER �/�/(•(� <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: 1A1111 NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> GL u Ali y-loo, y7w-22 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ) UNKNOWN <br /> D. CONTAINER CAPACITY: JZ 00 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (,}1_02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED ( 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIE( 1 0 <br /> 1( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 7 INCHES ( ) CM �Z_LUNKHOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 02 SINGLE WALLED ( 7 03 LINED <br /> D. (�.t�"(.1 CARBON STEEL ( 1 02 STAINLESS STEEL f l 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> T( ) 06 ALUMINUM l 1 07 STEEL CLAD l 1 08 BRONZE f ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />