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STATE IO NUMBER <br /> APPLICATION ,FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> i0 EN PERMIT ( 1 OS RENEWED PERMIT ( ) 07 TANK CLOSED t ) 09 DELETE' FROM FILE (NO FEE) <br /> �G 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME( OPPORATION,INOI DUAL OR FUOL AGENCY) PUBLIC AGENCY ONLY <br /> � <br /> 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> LI <br /> T STATE ZIP <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEM N�SUPE ISOR <br /> �5� � �— sp__ <br /> STREET A00'ESS NEAREST CROSS STREET <br /> CITY COU Y ZIP^ <br /> yi MAIL2NG ADDRESSCITY STAT ZI��� <br /> PHONO W,Ac A CODE JTYPLCF BUSINESS <br /> GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF COS, <br /> PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> 5 OAYSMEfLAST NAE fIPST) ANO PHONE W/APER CODE NI TS: NAME(LAST NAME FIRST) A 0 PHONE W/AREA OOE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION --l- <br /> A. 4LJ�A�IK ( ) 02 OTHER CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. TEAR INSTALLED ley ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 1 V 00 6 LLONS t ) UNKNOWN E. DOES THE CONTAINER STORE ( ) O1 HASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VE LE FUEL OR WASTE OIL ? (,L lES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 <br /> 01 Uf1LEADEO ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DI l ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION _A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES t 1 CM l 1 UNKNOWN <br /> 8. 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 02 NON-VAULTED ( l 03 UNKNOWN <br /> ,C. ( 1 01 DOUBLE WILLED � SINGLE WALLED 1 ) 03 LINED <br /> (0. CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> II - ( ) 06 ALUMINUM t ) 07 STEEL CLAD ( 1 08 BROt4ZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />