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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> f l 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> [ OWNER <br /> NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> l ) O1 FEO ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE 2IP <br /> [ I FACILITY <br /> FACIL TT NAME DEALS /FOPEMENISUPERVISOR <br /> STREET AODIESS NEAREST CROSS STREET <br /> I(f.3Zo < R <br /> CITY / COUNTY/ i/ ZIP <br /> MAILING ADDPESS CITYSTATE ZIP <br /> —�� e <br /> PHONE W/AVEA CODE TYPE OF BUSINESS <br /> . L l ) 01 GASOLINE STATION CO 02 OTHER jtf <br /> NVMBER C AINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEILAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(lAST NAME FIRST) AND PHONE W/APEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. t ) 01 TAM( ( ) 02 OTHER: CONTAINER NUMBER ` <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (rl UNKNOWN <br /> D. CONTAINER CAPACITY: aQOD GALLONS 1 ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE JK) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ! 01 YES f ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> .!Y) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM 1 ) 04 DIESEL ( 1 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (x) UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ()0 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) O1 ECARON <br /> WALLED 1 ) 02 SINGLE WALLED l 1 03 LINED <br /> D. t 1 O1 STEEL l 1 02 STAINLESS STEEL f ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( 1 INUM l 1 07 STEEL CLAD t 1 OB BRONZE f l 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 12 ( ) 13 OTHER: <br /> HSC04-070105 <br /> PAGE 1 <br /> l <br />