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STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />) 01 NEW PERMIT <br />I) 05 <br />RENEWED PERMIT <br />( ) 07 TANK CLOSED <br />( ) 09 DELETE FROM FILE (NO FEED <br />) 2_CONDITIONAL PERMIT <br />( ) 06 <br />AMENDED PERMIT <br />( ) 0$ MINOR CHANGE <br />(NO SURCHARGE) <br />a <br />I OWNER <br />ZIP <br />MAILING ADDRESS <br />_ <br />CITY <br />NAME(COPPORATION,INDIVIDUAL <br />OR PUBLIC <br />AGENCY) <br />PHONE WiAPEA CODE <br />IF YES CHECK APPROPRIATE BOX(ES): <br />PUBLIC AGENCY ONLY <br />D 02 OTHER <br />NUMBER CF CONTAINERS <br />RURAL AREAS ONLY : <br />TOWNSHIP <br />Q4 03 FIBERGLASS ( D 04 <br />( ) 01 FED ( D 02 STATE ( ) 03 LOCAL <br />---1STATE <br />STREET ADDRESS <br />06 ALUMINUM <br />( ) 07 STEEL CLAD ( ) 08 <br />BRONZE ( ) 09 COMPOSITE <br />CITY <br />( 1 12 <br />UNKNOWN ( ) <br />ZIP <br />II FACILITY <br />FACILITY NAME <br />( 01 TANK t ) 02 OTHER: <br />DEALER/FCREMEN/SUPERVISOR <br />STREET ACD?ESS <br />CONTAINER NUMBER <br />NEAREST <br />CROSS STREET <br />CITY <br />YEAR MFG: <br />COUNTY <br />YEAR INSTALLED % ( ) UNKNOWN <br />ZIP <br />MAILING ADDRESS <br />) UNKNOWN <br />CITY <br />) 01 WASTE 02 PRODUCT <br />STATE <br />ZIP <br />PHONE WiAPEA CODE <br />IF YES CHECK APPROPRIATE BOX(ES): <br />TYPE OF BUSINESS <br />01 GASOLINE STATION t <br />D 02 OTHER <br />NUMBER CF CONTAINERS <br />RURAL AREAS ONLY : <br />TOWNSHIP <br />Q4 03 FIBERGLASS ( D 04 <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 />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />( 01 TANK t ) 02 OTHER: <br />CONTAINER NUMBER <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />S <br />YEAR MFG: <br />C. <br />YEAR INSTALLED % ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 1 C)OVV GALLONS t <br />) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE <br />FUEL OR WASTE OIL ? ( 01 YES t ) 02 NO <br />IF YES CHECK APPROPRIATE BOX(ES): <br />D 03 LINED <br />( ) 01 UNLEADED �6 02 REGULAR ( ) 03 <br />PREMIUM ( <br />) 04 DIESEL ( ) 05 WASTE OIL <br />t ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />HSC04-070185 <br />L <br />PAGE 1 <br />A. THICKNESS OF PRIMARY <br />CONTAINMENT: <br />( ) GAUGE ( ) INCHES ( <br />) CM UNKNOWN <br />K) ( <br />) 03 UNKNOWN <br />B. ( ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) <br />02 NON -VAULTED <br />C. (3 01 <br />DOUBLE WALLED <br />( ) 02 SINGLE WALLED ( <br />D 03 LINED <br />D. ( ) 01 <br />CARBON STEEL <br />( ) 02 STAINLESS STEEL <br />Q4 03 FIBERGLASS ( D 04 <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) <br />06 ALUMINUM <br />( ) 07 STEEL CLAD ( ) 08 <br />BRONZE ( ) 09 COMPOSITE <br />( ) 10 NON-METALLIC <br />( 1 12 <br />UNKNOWN ( ) <br />13 OTHER: <br />HSC04-070185 <br />L <br />PAGE 1 <br />