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. . STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TAROK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 00 MINOR CHANGE (NO SURCHARGE) <br />OWNER <br />NAME(C RPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />( ) 01 FED I 1 02 STATE t ) 03 40CAL <br />STREET ADDRESS CITY STATE <br />II FACILITY <br />FACILIJY NAME <br />) 01 TANK ( 1 02 OTHERr <br />DEALER/FOREMEN/SUPERVISOR <br />e__C/Y" <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. <br />YEAR INSTALLED :a UNKNOWN <br />0. <br />CONTAINER CAPACITY: GALLONS t ) UNKNOWN <br />JE. DOES THE CONTAINER STORE: ( <br />) 01 WASTE Q.J,02 PRODUCT <br />STREET ADOPESS <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (CL 01 YES ( ) 02 NO <br />( ) 01 UNLEADED ( ) 02 REGULAR t ) 03 PREMIUM 1;1_04 DIESEL ( ) 05 WASTE OIL <br />NEAREST <br />CROSS STRlE� <br />CITY <br />COUNTY <br />ZIP <br />MAILING ADDRE S <br />CITY, <br />STATE <br />ZIP�c <br />© <br />PHONE W/ATEA CODE <br />TYPE OF BUSINESS <br />- <br />( ) 01 GASOLINE STATION <br />) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />OAYS: NAME(LAST NAMEFIRST) NO 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. <br />) 01 TANK ( 1 02 OTHERr <br />B. ( ) <br />CONTAINER NUMBER <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. <br />YEAR INSTALLED :a UNKNOWN <br />0. <br />CONTAINER CAPACITY: GALLONS t ) UNKNOWN <br />JE. DOES THE CONTAINER STORE: ( <br />) 01 WASTE Q.J,02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (CL 01 YES ( ) 02 NO <br />( ) 01 UNLEADED ( ) 02 REGULAR t ) 03 PREMIUM 1;1_04 DIESEL ( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES); <br />l ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PRIMARY CONTAINMENT: <br />( ) GAUGE ( ) INCHES t ) CM UNKNOWN <br />B. ( ) <br />01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) 04 02 NON -VAULTED ( ) 03 UNKNOWN <br />C. ( ) <br />01 <br />DOUBLE WALLED QC) 02 SINGLE WALLED ( <br />1 03 LINED <br />D.,t -101 <br />I <br />( ) <br />1 <br />12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 <br />UNKNOWN ( ) 13 OTHER: <br />) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br />HSC04-070185 <br />PAGE 1 <br />