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STATE ID NUMBER ` V '74 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (�1 O—j��IT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT { } 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED 1 ) 02 STATE 03 LOCAL <br /> STREET AC^,RE S CITY STATE ZIP 9 <br /> II FACILITY <br /> FACILITY NAt,E — DEALER/FCPEMEN/SUPEPVISOR <br /> I/ o 71ye, ID <br /> STREET ADD'E55� � l ��� NEAaEST CROSS<' ET <br /> CITY GGtt�� / r 'y/� COUNTY d ZIP <br /> MAILING ADDRESS CITY / STATE ZIP <br /> 'PHONE W,A"EA CODE / TYPE CF BUSINESS <br /> 01 GASOLINE STATION (k 02 OTHER <br /> NUMBER CF CONTAINERS_ P.URAt AREAS ONLY TOWNSHIP PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> E <br /> YS: NAMEfLAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> f <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 4 ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: -'5'5Z) GALLONS ( } UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( } 02 PRODUCT <br /> F. ODES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ! <br /> 01 UNLEADED { ) 02 REGULAR ( ) 03 PREMIUM ( ] 04 DIESEL 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( } INCHES ( ) CM ( UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WILLED J)a02 SINGLE WALLED f ) 03 LINED <br /> D. ( 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIEERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD l ) 08 BRONZE i } 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HBC04-070185 PAGE 1 <br /> i 40 <br />