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v STATE I0 NUMBER - <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> tJ41 O1 NEW PERMIT f l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( 106 AMENDED PERMIT ( ) 09 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP PORATION,INDIVIDUAL OR PUBLZC AGENCY) PUBLIC AGENCY ONLY <br /> 1 1 01 FED 1 1 OZ STATE l ) 03 LOCAL <br /> STREET ACOPESS CITY STATE 2IP <br /> �i f�ir )tza (��4Y <br /> II FACILITY <br /> FAC TY NAME DEALER/FOREMEN/SUPERVISOR <br /> STREET ADD?ESS NEAREST CROSS STREET <br /> CITY COVNTY ZIP <br /> MAILING ADD CITYSTATEZZP ,fes <br /> PHONE EA CODE TYPE OF BUSINESS <br /> ( ) 01 GASOLINE STATION !1)02 02 OTHER j<j <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> j <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAAY}S�NAME'LAS{��T�/NAME FIRST) AND PHONE W/AREA CODE NIGGHATSS:'AN AAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. f ) 01 TANG ( 1 02 OTHER: CONTAINER NUMBER <br /> /9 7Z <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( 1 NOWN <br /> D. CONTAINER CAPACITY: aD CYJ GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (.14 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES f l 02 NO IF YES CHECK APPROPRIATE BO%(ESI: <br /> 1 ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 4 DIESEL l ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> o <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE f l INCHES ( ) CM (�) UNKNOWN 'A' <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 7 02 SINGLE WALLED ( ) 03 LINED <br /> 0. (10 01 CARBON STEEL f ] 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ^`•r ) 06 ALUMINUM ( ) 07 STEEL CLAD f l OB BRONZE ( l 09 COMPOSITE ( l 10 NON-METALLIC <br /> 12 UNKNOWN ( ) 13 OTHER: <br /> HBC04-0 0185 PAGE 1 <br />