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`�J J /o STATE ID NUMBER �+ <br /> APPLICATION FOR PERMIT TO OPfERATE UNDERGROUND STORAGE TANK <br /> ( 11 01 NEW PERMIT ( ) 05 RENEWED PERMIT7 TANK CLOSED ( ) 09 DELETE FROM FILE fN0 FEE) <br /> ('1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 104 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAHE(COPV�ORATION.IN IVIDUAL OR PLIC AGENCY) PUBLIC AGENCY ONLY <br /> T ( ) 01 FED 1 1 02 STATE f ! 03 LOCAL <br /> STpEE ADORE �� CITY STATE YIP <br /> jAd <br /> 1 <br /> II FACILITY <br /> FACILITY N .E OEAIfR/FOAEMEN� VPEAVISOR <br /> I <br /> STREET RCC-ESS NEAPE T CROSS STREET <br /> 64 <br /> CITY COVNTY ZIP <br /> S2O� <br /> MAILING PQ ESS CITY STATE ZIP <br /> C <br /> PHONE WiP-EP CODE TYPE OF DVSINESS <br /> ---� <br /> ( 1 01 GASOLINE STATION ( 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM, (LAST NAME FIRST) AND <br /> PPHOONE"W,//AREA CODE NIGHT, S: NAMf(LPS NAME FIRST)_A O�PNONE W/AREA CODE <br /> /ffil/,�j,�`N,/ ��///l/ r(Y�,yT-•_i1C. . <br /> r <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> 02 OTHER: CONTAINER NUMBER <br /> 18. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: 'rl GALLONS 1 ) IRIKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ?SX) 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> f ) 01 UNLEADED f 02 REGULAR ( ) 03 PREMIUM f l 04 DIESEL f 1 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE 1 ) INCHES ( ) CM (2 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) - 1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED f ) 03 LINED WQW <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD f 1 08 BRONZE ( 1 09 COMPOSITE f l 10 NON-METALLIC <br /> 12 UNKNOWN l 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />