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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (�(! 01 NEW PERMIT i ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED i 1 109 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMEh9EO PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I GONER <br /> jNAMtICOWPORATICN,INDIV10UAL 00 PUBLIC AueNcy) PUBLICAGENCY ONLY <br /> i ) 01 FED t ) 02 STATE [ 1 03 LOCAL <br /> xr>tEET ADDRESS CITY STATE ZIP <br /> ��iI FACILITY <br /> PACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> sTfECT ADDRESS NEAREST CROSS STREET <br /> V <br /> cSTY COUNTY <br /> ZIP <br /> MAILING ADDRESS CITY STATE 2IP <br /> PHONE til/AREA CODE TYPE OF BUSINESS <br /> IA) 01 GASOLINE STATION [ ) 02 OTHER <br /> NUMBER OF CONTAINERS PYRAL AREAS ONLY TpWNSNIF RANGE SlC720N <br /> l�S2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME PIRST) AND �PHONE W/AREA CORE NIDHTS: 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. tk) D1 TANK ( ) 04 OTHER: CONTAINER NUMBER <br /> 1 <br /> B. MANUFACTURER (If APPROPRIATE): YEAR MFG:rr �� C. YEAR INSTALLED (A lwNOwN <br /> 0. CONTAINER CAPACITY: I O,C'0C GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) Ol WASTE ('C) 02 PRODUCT <br /> `. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES t ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 <br /> 01 UNLEADED ( ) 02 REGULAR ' 4,4 03 PREMIUM ( ) 04 DIESEL t ) 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRICTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t` 1 GAUGE ( ) INCHES t ) CM UNCNOI.N <br /> Ip S. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) y4 02 NON-VAULTEO ( ) 03 UNFNO N <br /> ,C. ( ) 01 DOUBLE WALLED I ) 02 SINGLE WALLED ( ) 03 LINED <br /> iD. (,Yi�01 CARBON STEEL i ) 02 STAINLESS STEEL [ ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE I 1 05 CONCRETE <br /> ( ) 06 ALUMINUM [ ) 07 STEEL CLAD ( ) OS BRONZE ( Y09 COMPOSITE [ ) 10 NON-METALLIC <br /> C ) 12 UNKNMM ( ) 13 OTHER: <br /> JSC04-070185 PAGE 1 <br /> R �' <br />