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*STATE ID NUMBER <br /> APPLICATION ,FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 ) <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( 107 TANK CLOSED <br /> E ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT f ) 08 MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> AYE[COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> [ ) <br /> 01 FED ( l 02 STATE ( ) 03 LOCAL <br /> CITY STATE ZIP <br /> TPEET A.C',PESS <br /> I FACILITY <br /> ACILITY NAME ffNEAPEST <br /> /SUPERVISOP <br /> .BEET ADC°ESS STREET ZIP <br /> ITY <br /> MAILINGACDPESS CITY SLATE ZIP <br /> PHONE W,AFEA CODE TYPE OF BUSINESS <br /> { ) O1 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> I11 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: HAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMEfIASt NAME F3RST)-AND-PHONE W�AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DDESCRIPTION <br /> A. ("I TANK ( ) 02 OTHER: CONTAINER NUMBER /ti` e✓� <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLED / ( � ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: �I, 1 � GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE Ivy 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 02 YES 1 ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (1.4 01 UNLEADED [ ) 02 REGULAR 1 ) 03 PREMIUM ( ) 04 DIESEL [ ) 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: � ( ) GAUGE (v INCHES ( ) CM 1 ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN U)dDERGROUN0 VAULT) (v)'02 NON—VAULTED 1 ) 03 UNKNOWN <br /> 4C. ("I DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. 1 01 CARBON STEEL 1 ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE f ) 09 COMPOSITE ( ) 10 NON—METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> i5C04-070185 <br />