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OSTATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> [J� 01 NEW PERMIT { ] 05 RENEWED PERMIT ( 107 TANK CLOSED i ) 09 DELETE FROM FILE (NO FEEl l <br /> f 1 02 CONDITIONAL PERMIT ( ] 06 AMENDED PERMIT ( ] 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER -- - <br /> NAME(COPPORATI N,INDIVIDUAL OP. PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 01 FED ( 1 02 STATE ( l 03 LOCAL <br /> ,STREET AC7RES5 V (ff CITY STATE 2IP <br /> II FACILITY - <br /> FACI lTy NAME DEALER/FOPEMEN/SUPERVISOP <br /> _._ tZ 6 <br /> STREET ACD'E S NEAP.E CROSS STPEET <br /> CITY CCUNTY - ZIP <br /> ?5-0 0� -- <br /> MAILING/ AODPESS CITY STATE .ZIP <br /> � <br /> PHONE W,AcEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION (tel 02 OTHER C4Q <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY : TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON _ <br /> ID <br /> AYS: NAME(LAST NAME FIPST) AND <br /> PHONE <br /> Wi/APER CODE NIGHTS: NAMEI LAST NAME FIRST) AND PHONE W/A EA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION —yy <br /> A. ('�i 01 TANK ( 1 02 OTHER- CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE)- YEAR MFG= C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( b UNKNOWN FEOOES THE CONTAINER STORE: (?0 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ES)= <br /> ( 1 <br /> 01 UNLEADED ( ) 02 REGULAR [ ] 03 PREMIUM ( ) 04 DIESEL (t'Q� 05 WASTE OIL f l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> FATHICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ] INCHES ( 1 CM (k6 UNKNOWN <br /> B. ( ] 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (Y) 02 NON-VAULTED 1 ] 03 UNKNOWN <br /> !C. ( ] O1 DOUBLE WALLED ( l 02 SINGLE WALLED ! ) 03 LINED <br /> D. f l 01 CARBON STEEL ( ] 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( b 05 CONCRETE <br /> ( ) OEC ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( l 09 COMPOSITE ( 1 10 NON—METALLIC <br /> f�C l 12 UNKNOWN ( 1 13 OTHER: <br /> L PAGE 1 <br /> HSC04-070185 <br />