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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> C 1 01 NEW PERMIT ( 1 05 RENEWED PERMIT 1 1 07 TANK CLOSEO ( ) 09 OELETE' FROM FILE (NO FEE) <br /> t -1 02 CONDITIONAL PERMIT Y C 1 06 AMENDED PERMIT v-f 1 09 MINOR CHANGE (NO SURCHARGE( <br /> i OWNER <br /> NAY_(COPPORATION,IN IVIDUAL OR FUSLIC ENCY) — PUBLIC AGENCY ONLY — - <br /> C I 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> STPEET ACRRE' CITY <br /> II FACILITY <br /> FACILITY N r " r DEALER/FOPEMEHZSVPERVISOP <br /> STPEET /:CC'ESS ] NEAPEST CROSS (STREET <br /> CITY dj COUNTY �-�- " XIP a/ <br /> ,,rJ d4� LI 1 A.) <br /> MAILING ACO'PESS )� CITY x � S��TE,r� ZIR�- <br /> r-,T <br /> PHONE W•ACEA CODE TYPE OF EUSINESS77-7 ` <br /> t 1 01 GASOLINE STATION (,%d 02 OTHER <br /> HU"10 CF CONYAIvErS PUPAL AREAS ONLY ; TOW!15tiIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS; NAME LA fT NAME JFIRST) AND PHONE W/AREA CODE NIGHTS' NAMEILAST NAME FIRST) AND PHONE W/AREA CODE r� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> r A. { 1 01 TAfiK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLED y 1 1 UNKNOWN <br /> D. CONTAINER CAPACITY: ,�q L/) GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 1 1 02 PRODUCT �—F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? t ) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( 1 01 U;/LEADED ( 1 02 REGULAR l ? 03 PREMIUM (/?/i. 04 DIESEL i 1 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TNICYNESS Of PRIMARY CONTAINMENT: ( I GAUGE f 1 ItICHES ( I CM I 1 UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) I 1 02 NON-VAULTED ( 1 03 UNKNOWN <br /> IC. f 1 01 DOUBLE WILLED OQ 02 SINGLE WAILED t 1 03 LINED <br /> i0. 1x1 O1 CARBON STEEL I 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> ) OF ALUMINUM ( ) 07 STEEL CLAD ( 1 06 BRONZE f 1 09 COMPOSITE ( 1 10 HON-METALLIC <br /> ( f 12 UNKNOWN i 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />