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0 0 STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />t )�01 NEW PERMIT ( ) CS RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />�T 02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />HAME(CORPORATION.INDIVIDUAL R PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />( ) 01 FED ( ),02 STATE ( 1 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />II FACILITY <br />FACILITY NAME <br />TANK t ) 02 OTHERr <br />DEALER/FOREMEN/SUPERVISOR <br />CONTAINER NUMBER <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. YEAR INSTALLED ( UNKNOWN <br />D. <br />STREET AODPESS <br />JE. DOES THE <br />NEAREST <br />CROSS STREET <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ,(�1 <br />(�4 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIE EL <br />(� <br />MSC04-070185 <br />t <br />a <br />PAGE 1 <br />CITY <br />COUNTY <br />ZIP <br />MAILING AODR SS <br />CITY <br />Lo©� <br />STATES <br />c, <br />ZIP <br />I �z� u� <br />t <br />l <br />! <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />— <br />( ) 01 GASOLINE STATION ( <br />02 0 E <br />NUMB!?R OF CONTAINERSRURAI <br />AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />-- ao9~� <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A.O1 <br />TANK t ) 02 OTHERr <br />) CM ( UNKNOWN <br />CONTAINER NUMBER <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. YEAR INSTALLED ( UNKNOWN <br />D. <br />CONTAINER CAPACITY: GALLONS ( ) UNKNOWN <br />JE. DOES THE <br />CONTAINER STORE: ( ) 01 WASTE 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ,(�1 <br />(�4 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIE EL <br />01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PRIMARY <br />CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />) CM ( UNKNOWN <br />B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 ON ( <br />) 03 UNKNOWN <br />C. ( ) 01 DOUBLE WALLED <br />l 02 SINGLE WALLED ( ) 03 LINED <br />D CARBON STEEL <br />( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( 1 06 ALUMINUM <br />( ) 07 STEEL CLAD ( ) 00 BRONZE ( 1 09 COMPOSITE <br />( 110 NON—METALLIC <br />( ) 12 UNKNOWN ( ) <br />13 OTHER: <br />MSC04-070185 <br />t <br />a <br />PAGE 1 <br />