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• SATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ! 101 NEW'PERMIT i ) 05 RENEWED PERMIT i ) 07 TANK CLOSED (x-I 09 DELETE FROM FILE (NO FEE) <br /> I 1 02 CONDITIONAL PERMIT [ ) 06 AMENDED PERMIT ( J 08 MINOR CHANGE (NO SURCHARG I <br /> I OWNER <br /> NAME(COPPORATION,INVIVIDUAL OR PUBLIC AGENCY) FPU13LOIC AGENCY ONLY <br /> ( � '� I1 FEq ( ! 02 STATE i ) 03 LOCAL <br /> STREET CRESS CI Y STATE ZIP <br /> ( L)E Celr, r i U f° - .C rxr c �}i- ` 5 ` <br /> II FACILITY <br /> FAC TTY NA;YE t DEALER?/FOPEMEN/SUPEPVISOP <br /> STREET A00 SS NEAP€ST CROSS STPEET <br /> CITY CCU TY � ZIP <br /> MAILING ADOPESS CITY + STATE ZIP <br /> PHONE W•A=EA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION 02 OTHERA� - <br /> NUP*5ER CF CONTAINEPS PUPAL APEAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS; NAr,E(LAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> pa,j <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION _ -- <br />� > A. ('� 01 TAHK ( ) 02 OTHER: - CONTAINER NUMBER- <br /> B. MANUFACTURER (IF APPROPRIATE ): YEAR MFG: C. YEAR INSTALLED f I UNKNOWN <br /> D. CONTAINER CAPACITY: jD 00C) GALLONS i J UNKNOWN E. DOES THE CONTAINER STORE: i 1 01 WASTE �<) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? N 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> f ) 01 UNLEADED 1 ! 02 REGULAR f ! 03 PREMIUM (X) OG DIESEL ( 1 05 WASTE OIL. i ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNES5 OF PRIMARY CONTAINMENT: ( ) GAUGE ( I INCHES ( ) CM ( ] UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN Ufl0ERGR0UND VAULT) 00 02 NON-VAULTED 1 ) 03 UNKNOWN j <br /> I <br /> 01 DOUBLE WALLED ( l 02 SINGLE WALLED 1 ) 03 LINED <br /> 01 CARBON STEEL ! J 02 STAINLESS STEEL ( ) 03 FIEERGLA55 f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( 1 06 ALUMINUM ! l 07 STEEL CLAD ( ) 08 BROIIZE ) C9 COMPOSITE 1 l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 113 OTHER: <br /> HSC04-070185 PAGE I <br />