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• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED 1 1 09 DELETEFROM FILE (NO FEEL <br /> 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER -_ <br /> NAME(COPPORATION.IN IVIDYAL OR PUBLIC AGENCY) I PUBLIC AGENCY ONLY <br /> l�� Ol FED 1 1 02 STATE ( 1 03 LOCAL_ <br /> STP'_ t��R�SCI Y �STATE �2Ip <br /> II FACILITY _ <br /> FACILITY NAMEDEALER/FOPEMENISy7 EPVISOP <br /> STREET ADL'ESS J NEAREST CROS STREET <br /> 52 <br /> CITY COUNTY 1 1 ZIP ^ / <br /> j� <br /> MAILING OPESSe __ <br /> ` I CITY v STATE� ZIP <br /> l <br /> PHONE W=pcECODE <br /> TYPE OF BUSINESS <br /> 1 01 GASOLINE STATION 1 1 02 OTtlA <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP SCCTION <br /> III 2f+ HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEILAST N MEN ME FIP�pNE /ARE'A1CODE 1j(J, NI{GGHTS: NAMEI(LLA,ST NAME/FIRST`I_4I PHONE WYA�A CODE <br /> COMPLETE THE FOLLOWING- 0- SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> TANK ( 1 02 OTHER: CONTAINER NUMBER I <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED j _ 1 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: C.E©� <br /> GALLONS ( 1 UNKNOWN E. GOES THE CONTAINER STORE: I 1 01 WASTE _02 PRODUCT <br /> F. 09,ES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 101 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 01 UNLEADED ( ) 02 REGULAR 1 ) 03 PREMIUM 1 ) 04 DY€�EL' l 1 05 WASTE OIL 1 1 06 OTHER <br /> ­ <br /> V CONTAINER CONSTRUCTION _ <br /> A. THICKNESS OF PRIMARY CONTAINMENT: _( ) GAUGE 1 ) INCHES ( 1 CM l 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) L-0-2 NON-VAULTED ( 1 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WALLED 1 1 02 SINGLE WALLED1 1 0I 03 LINED <br /> D. ( 1 01 CARBON STEEL I l 02 STAINLESS STEEL.- 03 FIBERGLASS ( 104 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD 1 1 O8 BROIJZE l ) 09 COMPOSITE ( 1 30 NON-METALLIC <br /> 1 1. 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE d <br />