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STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />(9i NEW PERMIT ( 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED l 1 09 DELETE' FROM FILE (NO FEE) <br />1 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE INO SURCHARGE) <br />I OWNER <br />NAe.!(COPPPORATION NDIVIDUAL OR PUBLIC ENCY) <br />STREET ACORESS <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />( 1 01 FED, ( ) 02 STATE ( l 03 LOCAL <br />C I T 1U TATE ZIP <br />YJ1— I S��T Il::_7' l J <br />FACILITY NAME <br />AP( <br />+532 - <br />DEALER/FOPEMEN/SUPEPVISDP <br />STREET aCC°ESS <br />NEADES4.111 <br />MANUFACTURER (IF APPROPRIATE I: <br />YEAR MFG: <br />-�S-T�PErET <br />0. <br />CITY <br />COUNTY <br />tr <br />ZIP��� <br />MAIIINGFOR ESS� � � CIT <br />STATE ZIP,/�� Y <br />--- <br />( 1 01 VULEAOED ( l 02 GULAR ( 1 03 PREMIUM ( <br />PHO'E W -AR • CODE <br />O� c, <br />TYPE OF BUSINESS <br />1 ) 01 GASOLINE STATION <br />( l 02 OTHER <br />NUMBER CR CONTAINERS -- <br />DURAL AREAS ONLY TOWNSHIP <br />RANGE SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(IAST NAME FIRST) AND PHONE W AREA CODE NIGHTS. NA E(LAST NAME FIRST) AND PHO E WiAREA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION - - <br />A. (.)gi <br />( l 02 OTHER: <br />CONTAINER NUMBER Z <br />C. 1 ) 01 DOUBLE WILLED (XAZ.•S'1+IGLE WALLED 1, ) 03 LINED, <br />D. ( 1 01 CARBON STEEL l ) 02 STAINLESS 3TEEL ( _(D,3 .I6ERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />( I 06 ALUMINUM l 1 07 STEEL CLAD ( 1 08 IZE I 1 09 COMPOSITE ( ) 10 NON-METALLIC <br />l 1 12 UNKNOWN ( 1 13 OTHER: <br />HSC04-070185 PAGE 1 <br />B. <br />MANUFACTURER (IF APPROPRIATE I: <br />YEAR MFG: <br />C. YEAR INSTALLED ( ) UNKNOWN <br />0. <br />CONTAINER CAPACITY: % GALLONS ( 1 UNKNO <br />DOES THE CONTAINER <br />STORE: ( 1 01 WASTE (y 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE <br />OIL ? ES ( <br />1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br />( 1 01 VULEAOED ( l 02 GULAR ( 1 03 PREMIUM ( <br />) 04 OI EL 1 1 05 WASTE OIL 06 OTHER <br />V <br />CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PP.IMARY CONTAINMENT: v I ) <br />GAUGE ( 4ZS l 1 <br />CM I 1 UNKNOWN <br />B. <br />I 1 01 VAULTED (LOCATED IN AN UNOERGROUND VAULT <br />l 0Z_NON-VAULTE0 I 1 <br />03 UNKNOWN <br />C. 1 ) 01 DOUBLE WILLED (XAZ.•S'1+IGLE WALLED 1, ) 03 LINED, <br />D. ( 1 01 CARBON STEEL l ) 02 STAINLESS 3TEEL ( _(D,3 .I6ERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />( I 06 ALUMINUM l 1 07 STEEL CLAD ( 1 08 IZE I 1 09 COMPOSITE ( ) 10 NON-METALLIC <br />l 1 12 UNKNOWN ( 1 13 OTHER: <br />HSC04-070185 PAGE 1 <br />