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• • o 0 1 <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> P� 01 NEW PERMIT f 5 RENEWED PERMIT ( 1 07 TANK CLOSED <br /> ( 1 09 DELETE FROM FILE (NO FEE) <br /> ) 0 <br /> l 1 02 CONDITIONAL PERMIT 1 l 06 AMENDED PERMIT f ) 04 MINOR CHANGE (NO SURCHARGE) <br /> II OWNER _ <br /> PUBLIC AGENCY ONLY <br /> NAME(�ORP/ORATION.INDIVIDUAL OR PUBLIC AGENCY) ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> TE ZIP <br /> L CITY STATE ZIP <br /> STREET ADDRESS' /' a/�,7 Z <br /> II FACILITY <br /> DEALER/FOREMEN/SUPERVISOR <br /> FACILITY NAME <br /> ( f <br /> NEAREST CROSS STREET <br /> STREET ADCRE�SS/I� �p <br /> f <br /> ZIP <br /> CCUNTT; 9'Sa© <br /> CITY <br /> CITY S�/l 0 <br /> MAILING ADDRESS �(f e <br /> _t(" ' <br /> PHONE W%AREA CODE TYPE OF BUSINESS <br /> ( ) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CONTAINEPS <br /> RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,EILAST NAME FIPST) AND PRONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> CAM m <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 01 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): L <br /> R MFG: C. YEAR INSTALLED�� l ) UNKNOWN <br /> 0. CONTAINER CAPACITY: �S� GALLONS f I UNKNOWN TAINER STORE: ( 1 O1 WASTE fxl 02 PRODUCT <br /> F. OOESOIHUNLEADED NER 5T02EMOTOR REGULARVEHI)L03F PREMIUMUEL OR WA WASTE OIL <br /> 04LOIESEL Ol 1E 05 WASTE2 IOl (I) 06SOTHERK APPROPRIATE BOXES 1: <br /> V CONTAINER CONSTRUCTION <br /> EA� THI,CKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( 1 INCHES ( ) CM (X) UNKNOWN <br /> O1 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (j(,1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. f 1 01 DOUBLE WALLED (\C) 02 SINGLE WALLED ( ) 03 LINED <br /> D. fx) 01 CARBON STEEL l ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 OS CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE f 1 09 COMPOSITE ( ! 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> -- PAGE 1 <br /> HSC04-070185 <br />