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STATE 10 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 108 MINOR CHANGE (NO SURCHARGED <br /> I OWNER <br /> NAME(CORPORATION.INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED 1 1 02 STATE 1 1 03 LOCAL <br /> STREET ACDRESS CITY STATE ZIO <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPFRVISOP f <br /> STREET ACDPESS NEAREST CROSS STREET <br /> CITY _ - - COUNTY ZIP - -- - - <br /> HAILING ADOPFSS -- _ - - CITY- STAT[ ZIP -- <br /> PHONE W'APEA CODE TYPE CF BUSINESS <br /> l 1 01 GASOLINE STATION 1 1 02 OTHER <br /> NUMBER CF CONTAINEPS PUP AI APEAS ONLY TOWNSHIP I RANOE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAr.E(LAST NAME FIPSTI AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIPST) AND PHONE W/APER CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 1 01 TAtlK I I 02 OTHER - CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEW: YEAR MFG: C. YEAR INSTALLED 1 1 UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE l 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? I 1 01 YES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> 1 1 01 U-ILEADED 1 1 02 REGULAR l 1 03 PREMIUM 1 1 04 DIESEL l 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE 1 1 INCHES 1 1 CM I 1 UNKNOWN <br /> B. f 1 01 VAULTED )LOCATED IH AN UNDERGROUND VAULT$ 1 1 02 NON-VAULTED I 1 03 UNKNOWN <br /> C. 1 1 01 DOUBLE WALLED 1 ) 02 SINGLE WALLED ( 103 LINED <br /> D. l 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM l 1 07 STEEL CLAD l 1 08 BRONZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> f 1 12 UNKNOWN l l 13 OTHER: <br /> ISC04-070185 PAGE 1 <br />