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STATE ID NUMBER 3 1 `\ (7 0'+- <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> � <br /> O1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ] 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> C _S' ck/1wn ( ) 01 FED ( ) 02 STATE 0(f 03 LOCAL <br /> STREET DDR ' STATE ZIP <br /> II FACILITY <br /> FACI STY NAM,yEDEALER/FOREMAN/SUPERVISOR <br /> STREET DDRESSNEAREST C SS S `"""'� <br /> T EET <br /> 2 L . MoLrLei I e <br /> CITY CO <br /> � ZIP <br /> culk o 1 f <br /> MAILINGINADDRISSlTs CITY -T� STAT ZIP <br /> 2Z < q�ZG/ <br /> --- r <br /> PHONE W/AREA CO�D/E TYPE OF BUSINESS /) <br /> 01 GASOLINE STATION 04 02 OTHER /(G <br /> NUMBER OF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYSA NAME(LAST NAME FIRST) AND PHONE W�pEA�CCD;/ N �SN'A�E� ST NAME FIRST) AND PHONE W/AREA CODE <br /> 00 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 TANK f ) 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED NKNOWN <br /> D. CONTAINER CAPACITY: &=rLGALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 7 01 WASTE 0Y02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( O1 YES f 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED 1 ) 02 REGULAR ( ) 03 PREMIUM (>d 04 DIE ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE UCT INCHES ( ) CM f l UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (W02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t ) 01 DOUBLE WALLED ( <'02 SINGLE WALLED ( ) 03 LINED <br /> 0. (tel)Jl CARBON STEEL f ) 02 STAINLESS STEEL l ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 9 12 UNKNOWN ( ) 13 OTHER: <br /> . HSC04-070185 PAGE 1 <br /> r i <br />