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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (�) <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED \Q ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 6iL 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADORES CITY STATE ZIP <br /> Cot Z, � � rtf C <br /> II FACILITY <br /> FACILITY NAME DEALERFOREMEN/SUPERVISOR <br /> STREET ADOPESe� NEAREST CROSS STREET <br /> CITY COUNTYD n � ZIP <br /> 7flCLToff GP <br /> MAILING ADDRESS � CITY STATE ZIP <br /> �O <br /> PHONE W/ACEA CODE TYPE OF BUSINESS <br /> ( ) <br /> 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CONT(�INERS PORAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HO/UR EMERGENCY CONTACT PERSON <br /> DAYS:`�AM�ST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) �ND-PHO�Q W/AREA CODE - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( ) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE)* YEAR MFG: C. YEAR INSTALLED 90 UNKNOWN <br /> D. CONTAINER CAPACITY: (D(DOD GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE t ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES (,k) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL (x) 06 OTHER 0 rPoli <br /> -- --- ---- 7211CK <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (t) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />