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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Vxl 01 NEW PERMIT l 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> f 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (N0 SURCHARGE) <br /> I OWNER <br /> HAME(COPPORATIOW,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 1 01 FED ( ) 02 STATE 1 1 03 LOCAL <br /> ATE <br /> STPEET ADnRESS CITY O STrL ZQIP S <br /> i� za Lb L L C sG <br /> II FACILITY <br /> FACS TY NAME DEALER/FOPEMEN/SUPERVISOR <br /> STR!!T POOPlSS NEPRlST CROSS STR ET <br /> CITY COUNTY ZIP <br /> Zow <br /> MAILING ADOPESS CITY STATE ZIIPP <br /> PHONE WiAPEA CODE TYPE OF BUSINESS <br /> ( 1 01 GASOLINE STATION (y) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,E(LAST NAME FIRST) AND PHONEW/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> .r^ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 01 TANK f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED l UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE Fi 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? t ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED l ) 02 REGULAR ( 1 03 PREMIUM !.Y_94 DIESEL ( 1 05 WASTE OIL t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES 1 1 CM ( UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) _LA 02 HON-VAULTED 1 ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 1 1 02 SINGLE WALLED l ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAD 1 ) 08 BRONZE 1 ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ()L 12 UNKNOWN l 1 13 OTHER: <br /> NSC04-070185 PAGE 1 <br />