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0 • <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND 5TOIA13E TANK <br /> [ 1 O1 NEW PERMIT ( 105 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( } 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INCIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET A.CDRES5 CITY STATE .ZIP <br /> G,q r�s- � <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> P d C) <br /> STREET FCD?ESS NEAREST CROSS STREET <br /> CITY <br /> COUNTY ZI <br /> P <br /> 5 �MAILING AODPESS CITYSTATE <br /> PHCNE WrLACEA CODE TYPE OF BUSINESS <br /> (l}() 01 GASOLINE STATION ( ) 02 OTHER <br /> NW'..BER CF CONTAINERS PUPAL APEAS CNLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> �D�AYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> l - - Lra- - / <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 02 OTHER= CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG= C. YEAR INSTALLED 8 1 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 6000 GALLONS ( ) UNKNOWN E.�THEER STORE: [ ) 01 WASTE ( )0 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 701 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES1= <br /> ( ) 01 UNLEADED i ) 02 REGULAR Oil) 03 PREMIUM ( ) 04 DIES [ ] 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: [ ) GAUGE ( 1 INCHES ( ) CM !!K ) UNKNOWN <br /> B. f 1 01 FAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON—VAULTED ( 103 UNKNOWN <br /> C. ( ) 01 DOUBLE WILLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (x ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( } 05 CONCRETE <br /> i } Oct ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE f ) 09 COMPOSITE ( 1 10 NON—METALLIC <br /> ( ) 12 UNKNOWN ( 113 OTHER: <br /> HSC04-070185 �— <br /> PAGE 1 <br />