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�P STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (Jhd 01 NEW PERMIT ( ) 05 RE4EWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> "Y02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT l ) OB MINOR CHANGE (No SURCHARGE) <br /> I OWNER <br /> — PUBLIC AGENCY ONLY <br /> )NAM C PORATION,I IVIDUAL OR PUBLIC AGENCY) ( ) 01 FED 1 ) 02 STATE ( O3 LOCAL <br /> Trac- <br /> CITY STATE ZIP <br /> STREET ADDRESS <br /> _----- <br /> II FACILITY <br /> MY NAME i _ REALE /FOREMAN/SUPERVISOR <br /> o �rc er row <br /> NEAREST CROSS STREET <br /> STREET DRESS <br /> Yap <br /> E COUNTY /�/ ZIP <br /> CITY <br /> Trate <br /> CITY STAT ZIP <br /> MAILING ADDRESS � �L <br /> �lOd � <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 1 01 GASOLINE STATION .02 OTHER <br /> NUMBER OF CONTAINER S RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME1LA T NAME FIRST) AND PHONE W/APEA COOK NIG TS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> �er 2L79 8�S S�S� �is��cker <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TAN( ( ] 04 OTHER: CONTAINER NUMBE _ <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED �UNCNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOESTHE CONTAINER STORE: ( 1 01 WASTE JGCr-02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 7 4W-01 YES 1 ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( l 01 UNLEADED 1 ) 02 REGULAR ( ) 03 PREMIUM Q"4 DIESEL t ) 05 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM k,-,ruw OWN — <br /> B. l ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 6R 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. [ ) 01 DOUBLE WALLED �02 SINGLE WALLED ( ) 03 LINED <br /> 0. 1 ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL l ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ) 06 ALUMINUM 1 ) 07 STEEL CLAD l ) 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ta�l2 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />