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'.- . <br />"TATE zo wuneEm <br />^ <br />° <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />01 NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED 09 DELETE FROM FILE (NO FEE) <br />02 CONDITIONAL PERMIT 06 AMENDED PERMIT ( ) 01� MINOR CHANGE (NO SURCHARGE) <br />L X - ___ <br />I OWNER <br />NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) 3LIC AGENCY ONLY <br />01 FED 02 STATE 03 LOCAL <br />STPEET ADOPESS CITY STATE ZIP <br />II FACILITY <br />FACILITY NAME <br />P <br />A. THICKNESS OF PRIMARY CONTAINMENT: <br />STREET ADVmESS <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />NEAREST qROSS STREET <br />YEAR MFG:/ft <br />C. <br />YEAR INSTALLED <br />UNKNOWN <br />0. <br />CONTAINER CAPACITY:�") <br />CITY <br />DOES THE CONTAINER STORE: <br />COUNTY <br />ZIP <br />MAILING ADDPESS <br />DOES THE CONTAINER <br />CITY <br />STATE ZIP <br />) 06 ALUMINUM ) <br />X, 01 U14LEADED <br />GASOLINE STATION OTHER <br />04 DIESEL 05 WASTE OIL <br />06 OTHER <br />OTHER: <br />.02 <br />NUMBER CF CONTAINERS <br />URAL AREAS ONLY <br />NSHIP <br />RANGE <br />SECTION <br />| III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />� <br />IV DESCRIPTION <br />V CONTAINER CONSTRUCTION , <br />A. THICKNESS OF PRIMARY CONTAINMENT: <br />GAUGE INCHES ( <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG:/ft <br />C. <br />YEAR INSTALLED <br />UNKNOWN <br />0. <br />CONTAINER CAPACITY:�") <br />00LI) GALLONS UNKNOWN]E. <br />DOES THE CONTAINER STORE: <br />01 WASTE <br />02 PRODUCT <br />F. <br />DOES THE CONTAINER <br />STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (,yi 01 YES 02 NO <br />IF YES CHECK APPROPRIATE BOX(ES): <br />) 06 ALUMINUM ) <br />X, 01 U14LEADED <br />02 REGULAR 03 PREMIUM <br />04 DIESEL 05 WASTE OIL <br />06 OTHER <br />OTHER: <br />V CONTAINER CONSTRUCTION , <br />| osx04-070185 <br />0 <br />A. THICKNESS OF PRIMARY CONTAINMENT: <br />GAUGE INCHES ( <br />) CM 00 UNKNOWN <br />( <br />) 03 UNKNOWN <br />B. 01 VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) <br />(K) 02 NON -VAULTED <br />C. 01 DOUBLE WALLED ( <br />02 SINGLE WALLED <br />03 LINED <br />D. 01 -CARBON STEEL <br />02 STAINLESS STEEL <br />06 03 FIBERGLASS 04 <br />POLYVINYL CHLORIDE 05 CONCRETE <br />) 06 ALUMINUM ) <br />07 STEEL CLAD 08 <br />BRONZE 09 COMPOSITE <br />10 NON-METALLIC <br />12 UNKNOWN ( ) 13 <br />OTHER: <br />| osx04-070185 <br />0 <br />