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• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> t D 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( D 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> - ( ) <br /> 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ACTRESS CITY STAT£ ZZP <br /> II FACILITY <br /> FACILITY NAME DEALER/FCREMEN/SUPERVISOR <br /> STREET ACD'ESS NEAREST CROSS STREET <br /> CITY COUNTY ZIP <br /> MAILING ADDPESS CITY STATE ZIP <br /> PHONE W,ACEA CODE TYPE CF BUSINESS <br /> - ( ) <br /> 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER CF CONTAINERS PURAI AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND 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. ( ) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. TEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN JE. DOES THE CONTAINER STORE: ( 1 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( D 01 TES t 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED t ) 02 REGULAR t ) 03 PREMIUM ( ) 04 DIESEL ( D 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM t ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED t 102 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( D 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> t ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( D 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 ,,��{{ PAGE 1 <br /> (. t <br /> J <br />