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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( l 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> INAME((;ORPORATION,I IVIDSJfL OR PUBLIC AGENCYI FPUBLIC AGENCY ONLY <br /> Q m -(`e-4 FED ( 1 02 STATE ( ) 03 LOCAL <br /> STREET ;t.COQESS CITY STATE IIP <br /> U r/zJ FirenL� Ccs.m � .z.3 <br /> II�FFAACILITY <br /> FACILITY NAME DEA R/FOREMEN/SUPERVISO <br /> tu) <br /> r e STREET ADOPESS <br /> NEAREST CROSS STREET <br /> CITY COUNTY <br /> .� ZIP <br /> an °! S <br /> MAILIyg p00;5S � CITY _ r- STAT ZIP <br /> �� ��,J( r'e.1'�CXI /9'� sZ <br /> PHONE E /C'DDE TYPE 0 BUSINESS <br /> (<_01 GASOLINE STATION ( 1 02 OTHER <br /> NUf!DE/Ry'L/C�F CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NA ,E(L ST A f RS ) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> // - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (}(f 01 TANK ( ) 02 OTHER: CONTAINER NUMBER `L <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: � GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (/v 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (Nr 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (k)' O1 UNLEADED ( ,) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) C}-rO2 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. ( ) 01 DOUBLE WALLED (XI- 02 SINGLE WALLED ( 1 03 LINED <br /> D. 0[ 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> L_ <br /> ( 1 12 UNKNOWN ( l 13 OTHER <br /> HSC04-070185 PAGE 1 <br /> c <br />