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i • ""1 �o <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> �( <br /> 01 NEW PERMIT ( l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> I ) 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I--0ONER <br /> (NAME(/rORPORATICN INDIVIDUAL OR PUBLIC AGENCY) — PUBLIC AGENCY ONLY <br /> 01 FED ( ) 02 STATE __ LOCAL <br /> .�. <br /> STREET 4ADPISS IC <br /> IT�� r\ STATE ZIP <br /> d 9'�zOZ <br /> II FACILITY <br /> FACILITY NNE ,^ r DEALER/FOREMAN/SUPERVISOR <br /> CC n-1i/IJ ( 4 58 vibe r <br /> STREET ADDRESS NEAREST CROSS STREET <br /> (off5. _ ..�.. <br /> COUCJ ` ZIP <br /> CITY ��a �` <br /> MAILING ADDRESS CITY STATE4 ZIP <br /> �J `.,... .,,::..v..r <br /> tA <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> ( l <br /> 01 GASOLINE STATION (x) 02 OTHER <br /> - -�---- <br /> NUMBER OF CO TAINERS4A J— RURAL AREAS ONLYTOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE I_L� <br /> NA E(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> �+1/al Ker may_ 9 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. !,�W1 TANK ( l 04 OTHER: - CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (-<r UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE_ 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 916 O1 YES (S9 02 NO IF YES CHECK APPROPRTATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM `UNKNOWN- <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 50 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (x-02 SINGLE WALLED ( ) 03 LINED <br /> D. (*' 1 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 110 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: _ -_ <br /> PAGE 1 <br /> HSC04-070185 <br />