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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t 1 O1 NEW PERMIT i ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 COtIOITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />[ OWNER <br /> NAME(COPPCRATION.INCIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> t ) 01 FED { ) 02 STATE { ) 03 LOCAL <br /> STREET AC^RESS CITY STATE ZIP <br /> II FACILITY <br /> FACILITY NAME DEALER/FCPEMEN/SUPERVISOP <br /> STREET ACC=ESS NEAREST CROSS STREET <br /> CITY COUNTY ZIP <br /> FLAILING ADDRESS CITY STATE ZIP <br /> PHONE WAVEA CODE TYPE OF BUSINESS <br /> - ( ) 01 GASOLINE STATION I 1 02 OTHER <br /> NUMBER CF CONTAINERS PUPA) AREAS ONLYTOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME( LAST NAME FIRST) AND RHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W�AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. t 01 TANK ( ) 02 OTHER: CONTAINER NUMBER A11 <br /> 114- <br /> B. MANUFACTURER (IF APPROPRIATE). YEAR MFG: (u C. YEAR INSTALLED 19J6 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: ,Jj GALLONS ( ) UNKNOWN JE. DOES THE CONTAINER STORE: t ) 01 WASTE (P1 62 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (+r)'01 YES [ ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> l i <br /> 01 UNLEADED (,/) 02 REGULAR 1 ) 03 PREMIUM l 1 04 DIESEL l ) 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> 1 <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE (INCHES ( 1 CM 1 ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) t-1-102 NON-VAULTED t ) 03 UNKNOWN <br /> IC. (V") 01 DOUBLE W4LLED [ 1 02 SINGLE WALLED 1 ) 03 LINED <br /> D. ( 01 CARBON STEEL t ) 02 STAINLESS STEEL 1 ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> 12 UNKNOWN t ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />