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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEED <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENOED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OONER <br /> NAME(CATiON,INDIVIDUAI OR PUBLINCv> PUBLIC AGENCY ONLY <br /> ®aaoRC E <br /> CITY <br /> (.� 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> 1^ — <br /> STREET DOPE STAT ZZP � <br /> ((II�I FACILITY <br /> Il /NAME DEALER/FOREM.AN/SUPERVISOR <br /> pgCg <br /> SIRE DD SS NEAREST,CROSS STFEET <br /> 6 <br /> CITY <br /> ---- <br /> COUNTY , ZIP _ <br /> ////// <br /> (A-1 <br /> ,ftp --�-- 66 _ <br /> [[ {o CITY STA E ZIP <br /> MAZLZN DDRE S �� <br /> PHONE W/AREA CODE TYPE OF BUSINESS ° <br /> ( ) O1 GASOLINE STATION t�f1 02 OTHER (4� <br /> NUMBER OF CONTAINERS RURAL 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. O1 TANK f ) 04 OTHER CONTAINER NUMBER / <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLED MOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (,%4-01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (w 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM t ) 04 DIESEL ( ) 05 WASTE OIL t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM P-13' UNKNOWN <br /> B. t l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (A<r 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 02 SINGLE WALLED ( ) 03 LINED <br /> D. 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />