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• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> CCONDITIONAL <br /> PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> NONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> rARJA ION,INDIV-IDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> O1 FED f 1 02 STATE ( ) 03 LOCAL <br /> RESS CITY STATE l � ,LITYAME DEALER/FO(REMEN/ ERVISO <br /> J , <br /> LMAILIT! <br /> D?ESS NEAREST CROSS STREET <br /> COUNTY IIPDDPESS C Tl, STATE� ZIP <br /> PHONE W,ACEA CODE TYPE) 01 GASOLINE STATION (X) 02 OTHER <br /> als(-�a3 3l OF BUSINESS <br /> NUMBER OF CONTAINERS RUPAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 241 HOUR EMERGENCY CONTACT PERSON <br /> DAY : NAME,LAST NAME FIPSTI AND PHONE W/AREA CODE NIGHTS: NAMEfLAST NAME FIRS ) AND PNONE W/AR A CODE <br /> 2�1 R�o� - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> IA. f)G SLJAW ( ) 02 OTHER: CONTAINERNUMBER I <br /> f <br /> B. MANUFACTURER (IF APPROPRIATE): - YEAR MFG: C. YEAR INSTALLED l ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS l 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE Y4 02 PRODUCT <br /> F. D`0�5 THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL �� �yy\'1 011�Y_ES f 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM l ) 04 04 x( ) 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 ) GAUGE ( ) INCHES ( ) CM ( ) UNKNOWN <br /> 8. f 1 O1 VAULTED (LOCATED IN AN UNDERGROUND VAULT) A 02 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. f 1 01 DOUBLE WALLED f GLE WALLED ( 1 03 LINED <br /> ID. >01__tCARBON STEEL ( ) 02 STAINLESS STEEL 1 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 6 ALUMINUM l ) 07 STEEL CLAD ( 1 OB BRONZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> 0 <br />