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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGRO ND STORAGE TANK <br /> t�) 01 NEW PERMIT ( 1 OS RENEWED PERMIT ( ) 07 TANK CLOSED t 1 09 DELETE FROM-FILE (NO FEE: <br /> (( 1 02 CONDITIONAL PERMIT t 1 06 AMENDED PERMIT t ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INDIVIDU l OR PU IC AGENCY) PUBLIC AGENCY ONLY <br /> ol <br /> ( 1 01 FED ( 1 02 STATE ( ) 03 LOCA( <br /> STREET ADDRESS CITY STATE ZIP <br /> owe, nwo <br /> y� II FACILITY <br /> ! FACILITY NAME DEALER/FOPEMEN/SUPERVISOR <br /> STREET ADDIESS NEAREST CROSTREET <br /> CITY COUNTx ZIP�p <br /> MAILING ADOPESS CITY STATE ZIP <br /> PHON! W,AvfA CODE TYPE OF BUSINESS <br /> (XI 01 GASOLINE STATION t 1 02 OTHER <br /> NUMBER co, C7 AINEPS DURAL AREAS ONLY TOWNSHIP PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,E(LAST NAME FIPST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) <br /> _AND-PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. t 01 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): v,Vn C> YEAR MFG: 7C. YEAR INSTALLED ) UNKNOWN <br /> 0. CONTAINER CAPACITY: bf-Z)ODGALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE l 102 PRODUCT <br /> F. DOES THE CONTAI14ER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f 1 O1 UNLEADED ( 1 02 REGULAR ( 1 03 PREMIUM t _1 04 DIESEL l ) 05 WASTE OIL t 1 06 OTHER —__— <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PP.IMARY CONTAINMENT: h( ) GAUGE ( 1 INCHES ( ) CM ( 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 ) 02 NON-VAULTED ; 1 03 UNKNOWN <br /> IC. (_) 01 DOUBLE WILLED ("j) 02 SINGLE WALLED ( 1 03 LINED <br /> 0. ( 1 01 CARBON STEEL 1 ) 02 STAINLESS STEEL t 1 03 FIBERGLASS t 1 04 POLYVINYL CHLORIDE t 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 1 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-0 0185 PAGE <br />