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STATE ID NUMBER <br /> Z_ <br /> APPLICATION FOR PERMIT TO OPERATE UND GROUND STORAGE TANK <br /> I SCS <br /> 0 <br /> 1 NEW PERMIT ( 1 05 RENEWED PERMIT ()ej 07 TANK GASP ,�'Z f 109 DELETE FROM FILE (NO FEE) <br /> _1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> W•Phkn I% S7 ry�.S 57eP,( l 1 01 FED ( ) 02 STATE f ) 03 LOCAL <br /> STREET ACDRfSS CITY $TATy' LIP <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMENISUPERVISOR <br /> __&✓_tfj�/&I * S A 5Tee-( <br /> STREET ACC+ESS NEAREST CROSS STREET <br /> CITY � COUNTY �� ZIP �1��� <br /> MAILING ADDRESS CITY $TATE 2IP <br /> PHONE WIAPEA CODE TYPE OF BUSINESS <br /> l 1 <br /> 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF CONTAINEPS RVP AL AREAS ONLY TOWNSHIP PA NGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY$: NAM,EILAST NAME FIPSTI AND PHONE W/APfA CODE NIOHTS: NAMEflAST NAME FSRST I-AND-PHONE W/AREA CODE <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: ii C. YEAR INSTALLED 1 ) UNKNOWN <br /> 0. CONTAINER CAPACITY: /0 p'd'I GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE� OIL ? f 1 01 YES ( 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> Y^ <br /> 1 1 <br /> 01 UNLEADED ( 1 02 REGULAR 1 1 03 PREMIUM Y 04 DIESEL l 1 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESSOF PRIMARY CONTAINMENT: f 1 GAUGE f 1 INCHES ( ) CM l 1 UNKNOWN <br /> 8. 1 101 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f 1 02 NON-VAULTED ( 1 03 UNKNOWN <br /> C. f 1 01 DOUBLE WALLED �) 02 SINGLE WALLED f 1 03 LINED <br /> D. X) 01 CARBON STEEL l ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM 1 1 07 STEEL CLAD [ 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER: <br /> HBC04-070185 PAGE 1 <br />