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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (' <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED l ! 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMEICQR PORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> y ) ( ) 01 FED f ) 02 STATE ( ) 03 LOCAL <br /> STEETADLRESS ,7�0 CITY STATE ZIP <br /> �( �SL,..(W/q L/Cl Goo Gt¢ -Y <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> STP ET AOL?ESS NEAREST CROSS STREET <br /> CIT COUNTY ZIP_ <br /> MAILING ADDPESS CITY STATE ZIP <br /> RD, <br /> E W%APEA C TYPE OF BUSINESS <br /> ( 1 <br /> 01 GASOLINE STATION 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,E(LAST NAMEPIPST) ANDD PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( ) 01 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: 4QQ GALLONS l ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (,(j 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 l <br /> 01 UNLEADED l 1 02 REGULAR l ) 03 PREMIUM ) 04 DIESEL ( 1 05 WASTE OIL [ ) 06 OTHER <br /> Laqvix <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM !.L UNKNOWN <br /> B. ( 1 Ol VAULTED (LOCATED IN AN UNDERGROUND VAULT) f l 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> C. ( I 01 DOUBLE WALLED f ) 02 SINGLE WALLED 1 ) 03 LINED <br /> D. 1 / 01 CARBON STEEL f ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD [ ! 08 BRO7ZE f 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (V,12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />