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0 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f ) 01 NEW PERMIT ( 1 05 RENEWED PERMIT f ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT ( ) 05 AMENDED PERMIT f ) 0$ MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED { 1 02 STATE { ) 03 LOCAL <br /> STPEET ADOPESS CITY STATE ZZP <br /> II FACILITY <br /> FACILITY NAME DEALER/FCREMEN/SUPERVISOR <br /> STREET ADD=ESS NEAREST CROSS STREET <br /> CITY COUNTY <br /> ZIP <br /> MAILING ADDPESS CITY ]STATE ZIP <br /> PHONE W'ArEA CODE TYRE OF BUSINESS <br /> ( 1 O1 GASOLINE STATION ( ) 02 OTHER <br /> NU"ER CP CONTAINEPS __]RUPAL AREAS ONLY : TOWNSHIP RANGE SECTION _ <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME( LAST NAME FIRST) AND PHONE W APER CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. f ) 01 TANK ( ) 02 OTHER CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE. ( ) 01 WASTE 1 ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 2 E 1 01 YES f ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> { ) 01 UNLEADED ( ) 02 REGULAR f ) 03 PREMIUM ( ) 04 DIESEL { ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( I CM [ 1 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( l 02 NON-VAULTED ( ) 03 UNKNOWN <br /> !C. ( ) 01 DOUBLE WALLED ( D 02 SINGLE WALLED f ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( i 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> [ 1 06 ALUMINUM f ) 07 STEEL CLAD ( 1 08 BR014ZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 <br /> PAGE 1 <br />