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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> r) 01 NEN PERMIT ( ) 05 RENEWED PERMIT l ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(C POR ATI NCIVIDUAL OR U/LI(C AGENCY) PUBLIC AGENCY ONLY <br /> ( ) <br /> 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br /> fTPElT AODRE CITY STAT ZI <br /> lim <br /> II FACILITY <br /> �FACIL T NAME DEALER/FOREMEN/SUPERVISOR <br /> STREET ADO=ES NEARE CROSS STREET <br /> c <br /> CITY COVN ZIP^ <br /> MAIL NG ADDRESS CITY STATE ZIP <br /> PHONE W%APEA CODE TYPEOF BUSINESS <br /> -?,4- <br /> _ ( 1 01 GASOLINE STATION _t e) 02 OTHER r To2 <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE ISEC <br /> TION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS' NAM,Ef LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> O <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. O1 TANK TAMC f 1 02 OTHER' CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): 6"('2EL ( YEAR MFG: C. YEAR INSTALLED (`t ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 114 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 ) 01 YES [ l 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> 1 ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM _!_yj04 DIESEL [ ) 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM ( UNKNOWN <br /> B. 1 ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 02 NON-VAULTED ( 1 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED l 1 03 LINED <br /> D. ( ) 01 CARBON STEEL [ 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM 1 ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( l 10 NON-METALLIC <br /> 12 UNKNOWN l l 13 OTHER: <br /> HBC04-070185 PAGE 1 <br />