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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> P01 NEW PERMIT f 1 05 RENEWED PERMIT l 1 07 TANK CLOSED 1 1 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP►ORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br /> STREET ACORlSS CITY STATE ZIP <br /> ly�z� �D Ct1 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMENISUPERVISOR <br /> Y G <br /> NEARE T CROSS STREET <br /> CW ! <br /> CITY COUNTY � ZIP <br /> MAILING ADOPESS CITY STATE ZIIPP�- <br /> PHONE W//-APEA CODE TYPE OF BUSINESS J� <br /> ( ) 01 GASOLINE STATION (y 02 OTHER <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,E)LAST NAME FIRST) AND 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 /> K. ( 01 TANK f ) 02 OTHER: CONTAINER NUMBER 157 <br /> B. MANUFACTURER (IF APPROPPRIATE)* YEAR MFG: C. YEAR INSTALLED IUQ,UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS 1 ) UNKNOWN I E. DOES THE CONTAINER STORE: ( ) 01 WASTE 12dd 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> 1 ) <br /> 01 UNLEADED ( 1 02 REGULAR ( ) 03 PREMIUM ()4 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> It <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE [ ) INCHES ( ) CM PO UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED f 1 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL l ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />