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STATE ID NUMBER o g 9 5 8 0.Z <br /> APPLICATION FOR PERMIT TO OPE ATE UNDERGROUND STORAGE TANK <br /> .c <br /> rL1 O1 NEW PERMIT ( 7 05 RENEWED PERMIT �'A7 TA K LOSE [ 1 09 DELETE FRCM FILE (NO FEET <br /> ( 11 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT f ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPCRATTON,,ItjDlVIDUAL OR PUBLIC AGENCY). PUBLIC AGENCY ONLY <br /> ( ) 01 FED ( ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> Z_ fK/AGfr .5gG�lu a6 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN�SVPERVISOR <br /> Com( <br /> STREET FDD-ESS NEAREST CROSS STREET <br /> CITY COUNTYZIF <br /> CS � <br /> MAILING ADDRESS CITY STATE ZIP <br /> PONE W/APER CODE TYPE OF BUSINESS <br /> ( ) 01 GASOLINE STATION 02 OTHER <br /> NUMBER CF CONTAINERS <br /> plUPALAREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,E(LAST NAME FIRS 1ANO PHONE 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. <br /> _YO) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE):Ut4t4� - YEAR MFG: C. YEAR INSTALLED f 'S UNKNOWN <br /> 0. CONTAINER CAPACITY: (�� GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: (J!) 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 0 <br /> 1 YES ( 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 OIE L ( ) 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM X UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1-1-0 2 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED 1 7 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM ( ) 07 STEEL CLAD f ) 08 BRONZE 1 109 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />