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>•: �� *00 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (.� O1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 DELETE FROM FILE (NO FEET <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) OQ MINOR CHANGE (N0 SURCHARGE) <br /> I OWNER <br /> NAY,IICOPPORATION.INCIV,,,jQUAL OR FUBLIc OENCYI PUBLIC AGENCY ONLY <br /> T�.I l 1 O1 FEO 1 1 02 STATE 1 1 03 LOCAL <br /> STREET ACOPESS CITY STATE ZIP <br /> II FACILITY <br /> FACIL YNAM£ OEALER REMEN,SUPERVISOP <br /> S T FEET ACC=£SS NEAREST CROSS STREET <br /> CITY COUNTY ZIP <br /> MAILING ADD ESS CITY STATE ZIP <br /> PHONE WIAPEA CODE TYPE OF BUSINESS <br /> /7f (W 01 GASOLINE STATION ( 1 02 OTHER r <br /> NUI'BER <br /> CF1 CONTAINER'S — RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 71 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NAY,EIl4ST NAM�JFIRST) AND PHONE W;FA CODE NIGHTS: NAMEILAST NAME FIRSTI-AND PHONE CODEka <br /> x <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER t <br /> i <br /> IV DESCRIPTION <br /> A. 1 O1 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MA14UFACTUREP (IF APPROPRIATE): YEAR MFG:IQ* C. YEAR INSTALLED ) UNKNOWN, <br /> 0. CONTAINER CAPACITY: 5-195- GALLONS ( ) UNKNOWN T E. GOES THE CONTAINER STORE: 1 1 01 WASTE 0& 02 PRODUCT <br /> F. DOES THE CONTAI14ER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> 1 I 01 U1ILEADED ( ) 02 REGULAR ( 1 03 PREMIUM Vj 04 DIESEL ( 1 OS WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION __- <br /> A. THICY.NESS OF PRIMARY CONTAINMENT: ( ) GAUGE f 1 INCHES ( ) CM l 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (Xl 02 NON-VAULTED t ) 03 UNKNOWN <br /> IC. (JC4 01 DOUBLE WALLED ( ) 02 SINGLE WALLED 1 103 LINEO <br /> 0. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL i 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> ( 1 06 ALUMINUM 1 1 07 STEEL CLAD l 1 OB BRONZE f ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN lxl 13 OTHER: �f� � �aU� (' 1.(�5(�+`-�•/� <br /> -'-"— PAGE 1 <br /> HBC04-070185 <br /> T �" <br />