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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> [� 01 NEW PERMIT Y( 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> f 1 02 CONDITIONAL PERMIT ITI 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> ;I OWNER <br /> - HAHE(COPPORATION.INDIV DUAL OR PUBLIC AGENCY ) PU8LIC AGENCY ONLY <br /> O1 FED t 1 02 STATE t } 03 LOCAL <br /> f STPEET ADRPESs <br /> STATE ZIP <br /> II FACILITY /r <br /> FACILITY NAME DEALEP/FCPEMEN'SUPf VISOP <br /> STPEET A NEAREST CROSS STPEET <br /> ,D <br /> CITY COU ZIP <br /> Ma LING ADDPESS CITY <br /> STATE ZIP <br /> c <br /> - � - A. aB <br /> PHONE W%ACEA CODE TYPE OF BUSINESS <br /> ` { 1 01 GASOLINE STATION 14q 02 OTHER <br /> NUrlSER CF CONTAINEFS PUPAL AREAS ONLY : TOWwSHIP — PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS; NAME(LAST NAME FIPSTI AND PHONE W/APEA CODE NIGHTS. NAMEILAST NAME FIRST) AND PHONE W/AREA CODE <br /> /1/1 -,/� 9 - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. [ 01 TA)(K f -1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEI: YEAR MFG: G. YEAR INSTALLED CS UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS t ) UNKNOWN E. DOES THE CONTAINER STORE: I 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? S�jQ 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> I 1 01 UNLEADED ( 1 02 REGULAR 1 ) 03 PREMIUM ( } 04 DIESEL ( ) 05 WASTE OIL t ) 06 OTHER <br /> {V� CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: I 1 GAUGE ( 1 INCHES I 1 CM D�LUNKNOWN <br /> S. ( 1 01 VAULTED (LOCATED IN AN UNOERGROUI(D VAULT) 2 NON-VAULTED 1 1 03 UNKNOWN <br /> �C. ( 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 1 01 CARBON STEEL f 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( } 04 POLYVINYL CHLORIDE ( } 05 CONCRETE <br /> f ) 06 ALUMINUM ( ) 07 STEEL CLAD l 1 08 BRONZE ( 1 09 COMP05ITE ( } 10 NON-METALLIC <br /> 1 12 UNKNOWN ( 1 13 OTHER: <br /> 1Sr04-070185 PAGE 1 <br /> r <br /> - - - .— ...� - .� -- - �__y...� _.�.�. -���-�� ter• r � � i <br />