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• ' STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK 1 <br /> ( ) 01 NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) I <br /> ISG 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) — JI <br /> I OWNER <br /> NAt'EtCOPPORA'ION. CIVIDUAL OR FUBLIC GENCY) PUBLIC AGENCY ONLY <br /> -- - F Q — ( ) 01 FED ( ) 02 STATE (- ) 03 LOCAL <br /> Of CILA <br /> F_'STCE'_'/—�{—EZIPTRSCT <br /> �UU <br /> II FACILITY <br /> FACILITY N "E DEALER/FOPEMEN/SUPEUISOP <br /> STREET ACD°ESS NEAPE CROSS STREET <br /> t ,— <br /> ytITY <br /> COUNTY �. ZIP <br />" r7AILIyC� ADDRESS STATE ZIP <br /> 'fr"J i y <br /> PHONE W'ACEA C DE TYPV OF BUSINESS <br /> GASOLINE STATION ( ) 02 OTHER <br /> NUMBER CF CO 'TAINRURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 2(+ HOUR EMERGENCY CONTACT PERSON <br /> 10AYS: NANE( LAST NAME FIRST) AND PHONE /AREA CODE N GHTS- 11E(LAST NAME FIRST) AND HONE W/APEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 1 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> s <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> 10. CONTAINER CAPACITY 10%000 GALLONS ( ) UNKNOWN E. ODES THE CONTAINER STORE: ( 1 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (q„jL]r YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)' <br /> 1 I 01 UNLEADED ( ) 02 REGULAR (N 03 PREMIUM ( ) 04 DIE-grL t ) 05 WASTE OIL ( ) 06 OTHER-_— _ — — <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PP.IMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM ( 1 UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ) 02 NON-VAULTED t ) 03 UNKNOWN <br /> IC. ( ) 01 DOUBLE WSLLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. 1 ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( 1 Ob ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> tiSC04-07.^185 , <br /> PAGE 1 <br />