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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK l <br /> ( LY01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) -1 <br /> (' ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) lI <br /> I OWNER <br /> PUBLIC AGENCY ONLY <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) <br /> �� ( ) .O1 FED t ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CCf-� STATE ZIP <br /> IIjj'— FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> L" <br /> STREET ADDRESS NEAREST CROSS STREET <br /> &J , ( <br /> CITY COUNT ZIP <br /> MAILING ADDRESS CITY STATE ZIP <br /> 5 — <br /> P NE W/A EA CODE TYPE OF BUSINESS <br /> (� GASOLINE STATION ( ) 02 OTHER <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(IAST NAME FIRST)—AND—PHONE W/AREA CODE <br /> Il -1 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> i <br /> IV DESCRIPTION <br /> A. ( TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> 1, <br /> I <br /> B. MANUFACTURER (IF APPROPRIATE): C�wS Gdl�.1)tiK YEAR MFG:New C. YEAR INSTALLED (UNKNOWN j <br /> D. CONTAINER CAPACITY: S!:—:;Q GALLONS t ) UNKNOWN JE. DOES THE'CONTAINER STORE: (11 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (-rtll YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR t ) 03 PREMIUM t ) 04 DIESEL (0-05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( d GAUGE ( D INCHES ( ) CM (KNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) t Q--�2 NON—VAULTED ( ) 03 UNKNOWN <br /> C. (Ler'01 DOUBLE WALLED ( ) 02 SINGLE WALLED .( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL t ) 02 STAINLESS STEEL ( 0-n FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( l 10 NON—METALLIC —� <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> I <br />