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0 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 44 f ) 01 NEW PERMIT f ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED f ) 09 DELETE FROM FILE (NO FEE1 <br /> 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT f ) 00 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME( OPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> c <br /> ( ) 01 FED f 1 02 STATE f ) 03 LOCAL <br /> STP'_ET ADORggS�S� CITY STATE ZIpP <br /> UJB 2 �(x�To�c <br /> II FACILITY <br /> FACILLIIITY NAME ''AA DEALER/FOREMEN! VPERVISOR <br /> / K <br /> STREET POOPES NEAREST CROSS STREET <br /> i CITY — COVN Y �— 2IP <br /> 0. Y <br /> MAILIN ADOPESS CITY STATE L A <br /> _� 7 V <br /> PnoNE w:APe'/A�coOE T(R) OF BUSINESS <br /> 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 277 HOUR EMERGENCY CONTACT PERSON <br /> OAY NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIG,H�u1fTS: NAME(LAST NAME FIRST) AND <br /> PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TANK ( 102 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED f ) UNKNOWN <br /> 0. CONTAINER CAPACITY: 7 D'U GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE f� 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? _Q0 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> f 1 <br /> 01 UNLEADED f ) 02 REGULAR t ) 03 PREMIUM 04 DIE L ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> I'. A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( 1 INCHES ( ) CM f UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (2f_02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ''') 01 DOUBLE WALLED f 02 SINGLE WALLED l 1 03 LINED <br /> D. (O1 CARBON STEEL f ) 02 STAINLESS STEEL [ 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> ( ) 06 ALUMINUM 1 ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />