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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 04 DELETE FROM FILE (NO FEE) <br /> f 102 COIIDITIONAL PERMIT I ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAr,E!COPvCPATION,INCIVIOU4L 09 PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 'Dp" A, � "i �� N�1�r — i ) 01 FED ( 102 STATE ( 03 LOCAL <br /> STCEET AD^ -RT'S CITY STATE Z _ <br /> R_d �✓ �L�f/ GIE� 5 ZG�S <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPEB SOP <br /> STREET ACCESS NEAREST CROSS STREET <br /> CITY COUNTY ZIP <br /> :rr MAILING ADDRESS _ CITY STAT ZIP <br /> PHONE 1J•AcE& CODE TtiPE CF BUSINESS ^' <br /> O1 GASOLINE STATION ( 02 OTHER <br /> NUrBEP CF CONTATNEPS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAr:EfLAST NAME FIPSTI AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A- f 01 TANK f 1 02 OTHER: CONTAINER NUMBER <br /> B_ MANUFACTURER iIF APPROPRIATE I= J G����s YEAR MFG: 1477 C. YEAR INSTALLED f } UNKNOWN <br /> 0. CONTAINER CAPACITY: Q�GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( I 01 WASTE i� 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 00 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES)- <br /> ( 1 01 UNILEADED ( 1 02 REGULAR ( ) 03 PREMIUM ( 04 DIESEL l 1 05 WASTE OIL i 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OFPRIMARYCONTAINMENT_—� _—f 1 GAUGE [ ) INCHES ( 1 CM UNKNOWN <br /> B, f 1 01 VAULTED (LOCATED IN AN UHOERGROUND VAULT) ( i 02 NON—VAULTED t 1 03 UNKNOWN <br /> IC- ( ) 01 DOUBLE WALLED (X 02 SINGLE WALLED i 1 03 LINED <br /> CARBON STEEL f ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br /> ALUMINUM 1 1 07 STEEL CLAD t ) 08 BRONZE ( 1 04 COMPOSITE ( 1 10 NON—METALLIC <br /> ( 1 12 L1aKNOWH l 1 13 OTHER: <br /> HSC04-070185 � PAGE 1 <br />