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a•. STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED t ! 09 OELETt FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAt..E(COPPOR T N IV PUBLIC AGENCY ONLY <br /> ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> ----- c, 1� ,�� �t CITY STATE ZIP <br /> STREET ORB`S /� /? <br /> II FACILITY G� C <br /> FACILITY NAME t J DEALER FOPEMEN/SUPERVISOP <br /> �^ NEAREST C OSS STREET <br /> STREET A00=ESS <br /> All <br /> CITY -6- ZIP <br /> COUNTY <br /> S � r <br /> .� CITY STATE ZI p <br /> Ijt`t MAILING <br /> PHONE W•ACEA CODE TYPE OF BUSINESS <br /> z,• ��/ _�� (A 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY : TnWNSHIP RANGE SECTION <br /> i" <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMELAS NAME FIPST) AND PHONE W/AREA CODE NIGHT NAME(LAS,T NAME FIRST) AND PHONE W/AREA CCODE <br /> E FOL TE`•FQ*M f;0R ACK rnNTAiK R <br /> IV DESCRIPTION ——_—_ <br /> TANK ( 1 02 OTHER' CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): � YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN- <br /> ---------- ----- �� <br /> 0. CONTAINER CAPACITY: Z� � GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ()d 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES)-. <br /> ( ) (LEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL ( ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( ) INCHES ( 1 CM _( 1 UNKNOWN — -- _ - <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) '(A 02 NON-VAULTED ( l 03 UNKNOWN <br /> C. ( DOUBLE WILLED ( ) 02 SINGLE WALLED ( l 03 LINED <br /> D. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL QV 93-FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM I ) 07 STEEL CLAD ( ) 08 ONLE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN l ) 13 OTHER: <br /> H5C04-070185 PAGE <br />