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yy V� � +¢ STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERA UNDERGRO ND STORAGE TANK <br /> h 01 NEW PERMIT ( ) 05 RENEWED PERMITI,>/,) 07 [ 1 09 DELETE FROM FILE (NO FEE) <br /> ,,*-1"-02 CONDITIONAL PERMIT t ! 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAM!(COPPORATION,INOIVIOUA OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ' <br /> I e-a-r'� t ) Cl FED 1 ) 02 STATE [ 1 03 LOCAL <br /> STREET AC??"RE55 rF j I Cl Y_ STATE ZIIP� <br /> /u. l ,;;�W6 <br /> II FACILITY <br /> FACILITY NAME DEALER/FCPEMEN/SUPERVISOpjf <br /> 4_ <br /> STREET AOP"ESS MEAP.ESCQWan STREET <br /> �y <br /> CITY COU ZI <br /> MAILING ADOPESS CITY SATE. <br /> RHONE WA.rE CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION [ 02 OTHER <br /> NUMBER CF``CONTAINEPS DURAL AREAS ONLY TOWNS)iIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME PST) AND PHON W/A EA CODE) NIGHTS: NAME(LAST NAME FIRST) AND PHONE WiAREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 6 --- <br /> 41 TANK f 102 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED A-) UNKNOWN <br /> D. CONTAINER CAPACITY: c gon GALLONS ( l UNKNOWN JE. DOES THE CONTAINER STORE: ( ) 01 WASTE l 2 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WAST OIL ? ( 1 01 YES ( NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> 1 ) 01 UNLEADED { ) 02 REGULAR t ) 03 PREMIUM 04 DIESEL l 1 ASTE OIL d ) 08 OTHER <br /> CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( I GAUGE [ ] INCHES t ) CM d ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) NON-VAULTED [ ) 03 UNKNOWN <br /> IC. f ) 01 DOUBLE WILLED SINGLE WALLED { 103 LINED <br /> D. I ►1 CARBON STEEL [ 102 STAINLESS STEEL 1 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE d ) 05 CONCRETE <br /> �f 106 ALUMINUM [ ) 07 STEEL CLAD l l 08 BRONZE ( 1 09 COMPOSITE t ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN l 113 OTHER: <br /> HSC04-0 0185 PAGE 1 <br /> 1 4( - 40 <br />