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STATE NUMDER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STOR E TANK <br /> 04:�O1 NEW PERMIT ! 1 05 RENEWED PERMIT ( ) 07 TAN( CLOSED A 09 DELETE FROM FILE (NO FEE) <br /> I 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OPINE <br /> [NAMEiCOP���PORATION,INDIVIDUAL OAPUBLICAGENCY� PUBLIC AGENCY ONLY <br /> ( ) 01 FED ( 1 02 STATE Ole 03 LOCAL <br /> REET A <br /> CITY STATE ZIP <br /> I I I ccn ��cci C/Q— S <br /> II FACILITY <br /> FACILITY NA E S!'( (C.� DEl)LE R/FOREMAN/SUPERVISOR <br /> S T R EE <br /> NEAREST CROSS T �--� <br /> CITY <br /> CoutiTy <br /> �-c11 , ZIP <br /> MAILING ;D p`PE$S / CIT e <br /> /10 <br /> { ST LIP ice <br /> C 533 <br /> PHONE W/ARE TYPE OF BUSINESS <br /> 01 GASOLINE STATION ft-02 OTHER Ya <br /> NUMBER OFYT <br /> RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> PS <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 /> CkLer _209 <br /> 503 f - 8�3- I 20 - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (u(01 TANK ( ) 04 OTHER: CONTAIN NUMBER <br /> 7 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED.L96P"f ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (A,+ 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? f�.Di YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) O1 UNLEADED ( 102 REGULAR ( ) 03 PREMIUM (W 04 DIESEL ( ) 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( ) INCHES ( ) CM (kT UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1S)0-02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED Qjr02 SINGLE WALLED ( 7 03 LINED <br /> D. f ) 01 CARBON STEEL f 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( l 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE [ ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> f>� UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 <br /> PAGE 1 <br />