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-- `" STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> P01 NEW PERMIT 1 1 05 RENEWED PERMIT L 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> P 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT 1 ) OB MINOR CHANGE (ND SURCHARGE) <br /> I OWNER <br /> NAME) OP PORAtION.INDIVIDUAL OR PUBLIC /SOCNQY) PUBLIC AGENCY ONLY <br /> o , ( ) 01 FED l 1 02 STATE 1 03 LOCAL <br /> STREET ACTRESS CITY STATE 2IP <br /> ull / <br /> II FACILITY <br /> FAC Y NAM! DEALER/FOREMEN <br /> UPCRYISOR <br /> uc <br /> STREET P00°ES NEAR! CROSS STMT <br /> 170 t Ro <br /> CITY COUNTY izip <br /> SrocemkL, ?s <br /> MAILING ADDPESS CITY STATE ZIP <br /> C <br /> PHONE W/APEA CODE TYPEOF BUSINESS <br /> 1 01 GASOLINE STATION q) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OAj NAM,! LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: N Cf LAST NAME FIRST) AND PHONE W/AREA CODE <br /> -P4N-P dao u D - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TANK f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): - YEAR MFG C. YEAR INSTALLED JW ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: «j 0400 GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE f 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (?0 01 UNLEADED 1 l 02 REGULAR l ) 03 PREMIUM ( ) 04 DIES L l ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM t1a UNKNOWN <br /> B. (, ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) %-) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED 0<'02 SINGLE WALLED 1 1 03 LINED <br /> D. O� O1 CARBON STEEL f ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM l ) 07 STEEL CLAD t ) 08 BRONZE 1 ) 09 COMPOSITE ( l 10 NON-METALLIC <br /> I ) 12 UNKNONN ( 1 13 OTHER: <br /> HSC04-070185 PAGE I <br /> 4� - <br />