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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (X�j NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> r-) 02 CONDITIONAL PERMIT t ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I LONER <br /> NAMTE(CO PORATICN NDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> S 01 FED ( ) 02 STATE Oil 03 LOCAL <br /> �� �y o L <br /> SS CITY,/ STATE <br /> TREE A ZIP��Q <br /> II FACILITY <br /> FACILITY NAME DEAt.ER/FOREMAN/SUPERVISOR <br /> v T _V.11 r <br /> STREET ACDRESS / NEAREST CROSS TREET <br /> J C r r " <br /> CITY COUNTY ZIP <br /> c r. �x r .�o a u;rvN <br /> MAILING ACDRESS � CITY ��C�/ � ST E ZIP <br /> PHONE W/A=EA CODE - ��— _ TYPE-OF BUSINESS <br /> ( l <br /> 01 GASOLINE STATION (x) 02 OTHER Cp('P• Y' <br /> NUMBER OF CONTAINERS_ RURAI AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: /"AME(LAST NA E FIRST) AND PHONE W//A <br /> REA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> � <br /> al <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (>t-01 TANK ( ) 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (�CNOWN <br /> D. CONTAINER CAPACITY: BSO GALLONS ( l UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTEkr 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE• FUEL OR WASTE OIL ? ( ) 01 YES Ot4 02 NO IF YES CHECK APPPOPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 051TA= OIL 4•i 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM _(!&t UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ('19f 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (-sl 02 SINGLE WALLED (_) 03 LINED <br /> D. (<�_ CARB04 STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM [ ) 07 STEEL CLAD ( l 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> . HSC04-070185 <br />