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0 <br /> STATE IO NUMBFR <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ,X) 01 NEW PEPHIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED t ) 09 DELETE FROM FILE (NO FEE) <br /> I F 3 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) OS MINOR CHANGE tN0 SURCHARGE) <br /> 1_ <br /> I OWNER <br /> :,Wit(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( 3 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STRECT ADDRESS CITY STATE ZIP <br /> i <br /> i <br /> zI FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> ;STREET ADDRESS NEAREST CROSS STREET <br /> I <br /> :CITY COUNTY ZIP <br /> I <br /> !MA.ILING ADDRESS CITY STATE ZIP <br /> :,HONE W/AREA CODE TYPE OF BUSINESS <br /> (X) 01 GASOLINE STATION 1 ) 02 OTHER <br /> vjm"R OF CONTAINERS Rl1RAL AREAS ONLY TOWNSHIP r RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND ,PHONE W/AR A C70E NIGHT&: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> IA. (�) 01 TANK ( 1 04 OTHER: CONTAINER h`E]MBER <br /> fs. MANUFACTIAt€fi (IF APPROPRIATE1. YEAR MFG�`� C. YEAR INSTALLED ( ! UMCNOWN <br /> 1I D. CONTAINER CAPACITY: C 1 (j GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: i ) 01 WASTE (-') 02 PRODUCT <br /> �F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 1 t'() 01 YES [ 1 02 NO IF YES CHECK APPROPRIATE 80XIES): <br /> IX') 01 UNLEADED ( ) 02 REGULAR t ) 03 PREMIUM' I ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> d CONTAINER CONSTRUCTION <br /> r <br /> THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM i ) UNKNOWN <br /> a <br /> B. t ') 01 VAULTED ILOCAT€D IN AN UNDERGROUND VAULT) [I ) 02 NON—VAULTED ( ) 03 MWMWN <br /> �r. (( ) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED 1 ) 03 LINED <br /> C. k'1) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS 1 ) 04 POLYVINYL CHLORIDE ( •I 05 COtJCRETE <br /> s ( ) 06 ALUMINUM t ) 07 STEEL CLAD ( ) 08 BRONZE [ 1 09 COMPOSITE S ) 10 NON—METALLIC <br /> C ! 12 UNKNOWN S ) 13 OTHER: <br /> �SC04-Oid1B3 PAGE 1 <br /> ( <br />