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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT I ) 08 MINOR CHANGE (NO SURCHARGE) <br /> `---- ---- - - <br /> I OWNER <br /> NAM!(COPVORATION,INCIVIDURL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> r l 1 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br /> �STP!ET ACTRESS 'CITY STATE !IP <br /> II FACILITY <br /> FACILITY NAMt DE&LER/FOPEMENISUPERVISOP <br /> STREET ACL"ESS NEAREST CROSS STREET <br /> CITY COUNTY !IP <br /> M4ILING ADDPESS CITY STATE YIP <br /> PMONE WIAVEA CODE TYPE OF BUSINESS <br /> ( 1 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE ION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME( LAST NAME FIPST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWI14G ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />` A. ( 1 01 TANK t 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS ( I UNKNOWN( If. DOES THE CONTAINER STORE: ( 1 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ° ( ) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f ) 01 U1ILEADED ( 102 REGULAR ( 1 03 PREMIUM ( T 04 DIESEL ( 1 05 WASTE OIL t ) 06 OTHER <br /> •V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( I INCHES ( ) CM f 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 HON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( 1 02 SINGLE WALLED 1 1 03 LINED <br /> 0. 1 ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL t ? 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> [ ) 06 ALUMINUM ( 1 07 STEEL CLAD l 1 08 BRONZE f 1 09 COMPOSITE [ ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN t ) 13 OTHER: <br /> HSC04-0:0185 PAGE I <br />