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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Ixi <br /> 01 NEW PERMIT l 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> _I 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPnORA,TION.INDIVIDUAL OR PUBLIC AGENCY) GG PUBLIC AGENCY ONLY <br /> VVY/571• �7��Es 57�r�. l 1 01 FED 1 ) 02 STATE 1 1 03 LOCAL <br /> STREET ACORESS� ^ CITY STATE. <br /> 22 V/�A 4CJ <br /> II FACILITY <br /> FACILITY N4Y1Ee / / �!e DEALER/FOPEMENISVPERVISOP <br /> STREET ADOPESS 7!`D'•L NEAREST CROSS STREET <br /> CITY � � � , n /h � COUNTY ZIP <br /> MAILING ADDRESS(Q (�J CITY STATE ZIP <br /> PHONE W,APEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION l 1 02 OTHER <br /> NU"EP CF CONTAINCC IPU <br /> AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST)-ANO-PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION ✓ <br /> A. f 01 TAIIK 1 1 02 OTHER: CONTAINER NUMBER / <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> 0. CONTAINER CAPACITY: /0) QTJ'd GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER 5TORE: 1 l 01 WASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 ) 01 UNLEADED (>O 02 REGULAR 1 1 03 PREMIUM l 1 04 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: l ) GAUGE 1 1 INCHES ( ) CM 1 1 UNKNOWN <br /> B. 1 1 01 VAULTED ILOCATEO IN AN UNDERGROUND VAULT) 1 1 02 NON-VAULTED ( 1 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (A) 02 SINGLE WALLED ( 1 03 LINED <br /> D. 1711 01 CARBON STEEL f 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD 1. 1 OB BRONZE ( 1 09 COMPOSITE f 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />