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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 01 NEW P€RMIT 6 1 05 RENEWED PERMIT C ) 07 TANK CLOSED C 1 09 DELETE FP,OM FILE IND FEE) <br /> ( 1 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT 1 ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I 0WNER _--- - <br /> (: _ ----- ---------- ------ AT- ------- PUBLIC AGENCY ONLY <br /> `;NAME!CO;POPATION.INOiVIDUAL OR PUSLIC AGENCY) <br /> l ! 01 FED ( 1 02' STATE [XT 03 LOCAL <br /> --- �_!--_-1--�__ .�_ _ . <br /> Czs <br /> ITY STATE' ZIP <br /> - - -�=^_w�;_� �=f'� X20 <br /> II FACILITY -- <br /> FACILITY NAME <br /> p-- OEALEP/FOPEMCN�SUPERVISOP <br /> t1t_— <br /> 1S:FEET AOC'Ess NEAREST CQCSS STPEET <br /> HVJ�l '19 <br /> CITY COUNTY AO 0 U r ZIP <br /> MAIL OITY STA^T{E� LIP <br /> Com. <br /> Amon— <br /> PHONE W.AcEA. CODE TYPE OF BUSINESS <br /> r ( 1 01 GASOLINE STATION (X) 02 DTHER <br /> NUMBER CF CCNTAINEPSRURAL AREAS ONLY T_ow <br /> NSHIP - RANGE SECTION <br /> 111 24 HOUR EMERGENCY CONTACT PERSON � `- -- -- _ - <br /> iDAYS: NAM„Er LAST NAME FIPST) AND PHONE W/APEA CODE - INIGHTS: NAMEFLAST NAME FIPSTI AND PHONE W/AREA CODE <br /> E- - +1`s� ► �— - o�” a-��- 2�' III b f-) L) � t _ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORA FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> A. � ) OL TANK C 1-02 OTHER: ---- -'- - - --- - - � - CONTAINER NUMBER �B. MANUFACTURER MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> 0. CONTAINER CAPACITY= -10 00 GALLONS ( ) UNKNOWDOES THE CONTAINER STORE: 1 1 01 WASTE 02 PRODUCT - <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK <br /> :1PPROPRIATE BOX(ES). <br /> 1 1 01 UNLEADED ( 1 02 REGULAR C ) 03 PREMIUM l ) 04 DIESEL C 1 05 WASTE OIL OKI 06 OTHER R <br /> V CONTAINER CONSTRUCTION -_.___-_ <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE i ) I)ICHES I ) CM ) UNKNOWN <br /> B. ( 1 01 FAULTED ILOCATED IN AN UNOERGROUND VAULT) 1 02 NON-VAULTED ( 1 03 UNKNOWN <br /> (C. ( ) 01 DOUBLE WILLED (Y) 02 SINGLE WALLED ( 1 03 LINED <br /> 0. ("k? 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIFERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 06 ALUMINUM l ) 07 STEEL CLAD I ) 08 BRONZE f ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> l ) 12 U(1KNOWH ( 1 13 OTHER: <br /> -- -- - ---- - - - - . . --- --------- <br /> HSC04-070185 PAGE 1 <br />