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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (pjr01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGEI <br /> I OPINE <br /> NAME(CO PORATION. DIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> TmcO1 FEE) t ) 02 STATE 1 03 LOCAL <br /> STREET ADDRESS CITV STATE 2IP <br /> 32Stots- <br /> II <br /> o S <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREM N/SU ER VISOR <br /> D a - Ser7/1C 8f Ode <br /> STREET A DRESS NEARE^ST/CROSS ST EET c <br /> 11/. J <br /> CITYCOUNTY ZIP <br /> r- <br /> MAILING ADDRE S ^ CITE STAT ZIP <br /> r kc C �3 <br /> PND2O AaEACODE J T( ) OF BUSINESS <br /> 01 GASOLINE STATION (,&_OZ OTHER cn r o, vo,V' <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NAME(LAST N 4 CSS) AND�PHONE W^ EA CODE 3( NIGH 7�$: tE(LAST VtMME FIRST 5= AR <br /> E EA COO <br /> el <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION /y,f( <br /> A. 1 O1 TANK ( 1 04 OTHER: CONTAINER NUMBER y" <br /> B. MANUFACTURER IIF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED- Z!2Z±( ) UNKNOWN <br /> D. CONTAINER CAPACITY: Y Q0'G GLONS [ l UNKNOWN E. ODES THE CONTAINER STORE: ( 1 01 WASTE (�02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 YES 1 ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f ) <br /> 01 UNLEADED 1 ) 02 REGULAR ( ) 03 PREMIUM Ih�04 DIESEL l ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( I INCHES ( ) CM L%ITNKNOWN <br /> B. l 7 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) OCT 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 1 ) 01 DOUBLE WALLED (" SINGLE WALLED l 1 03 LINED <br /> D. 1 ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 7 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> cx� ) 06 ALUMINUM 1 ) 07 STEEL CLAD l ) 08 BRONZE ( 1 09 COMPOSITE ( ] 10 NON-METALLIC <br /> j2 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> L <br />