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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 01 NEW PERMIT l ) OS RENEWED PERMIT 07 TANK CLOSED ) 09 DELETE FROM FILE IND FEE) <br /> 1 1 02 CONIDITIONAL PERMIT _1_1 06 AMENDED PERMI MINOR CHANGE (NO SURCHARG <br /> I OWNER <br /> NAY, � ,ION,I VIED(AL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> K yTL' (�jT/` 1 1 01 FED 1 ) 02 STATE f 1 03 LOCAL <br /> STp-!1 PCORESS CSTY � STATE ZIP <br /> �v-lN �laen�y Cti, moo, <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPERVISOR <br /> STF[ET AOD-ESS NEAREST CROSS STREET <br /> CITY COV TY ZIP <br /> MAILING ADDRESS CITY F STATE ZIP <br /> PHONE WARE, CODE TYPE OF BUSINESS <br /> po-fV;/2 && ( ) 01 GASOLINE STATION f 1 02 OTHER <br /> NUMBER OF CONTAINEPS VPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(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 /> A. f 1 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY WOO GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE• ( 1 01 WASTE (&,1'02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 101 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> l 1 01 UNLEADED ( 1 02 REGULAR l ) 03 PREMIUM l 1 04 DIESEL l ) 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( I CM I ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND) VAULT) 1 1 02 NON-VAULTED ( 1 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WALLED 1 1 02 SINGLE WALLED l 1 03 LINED <br /> D. 1 ) 01 CARBON STEEL I 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM l ) 07 STEEL CLAD 1 1 OB BRONZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> f_) 12 UNKNOWN l 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />