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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 /> 02 CONDITIONAL PERMIT ( ) 06 AMEND ED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I GONER <br /> NAME(CORPORATION,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED ( 1 02 STATE ( l 03 LOCAL <br /> STREET ADDRESS IO UNlV645AL GIT`/ PLA-ZA CITY UNIVFERSAL G.(TY STATE ZIP <br /> I o. 81 3'7 c _ <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR/ <br /> STREET ADDRESS NEAREST CROSS S EET <br /> Hyv w QAX.At5,, <br /> CITY COU TN Y ZIP <br /> S kc,-V-- .lo" SAS I w , 9 'S� U 0 <br /> MAILING ADDRESS CITY STATE ZIP <br /> S-C C-K 4c,A) 0y <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> Vc)) > > —7 ()0 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> EyAca ('<<��orn�2 S��u L� CEti z NRich l�> ; G1 ID <br /> (3CO) 31(_a <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. t 01 TANK ( l 04 OTHER: CONTAINER NUMBER <br /> x2XE5 /98Lf <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY' 1(0GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( l 01 WASTE ()Q 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (IV 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> l ) <br /> 01 UNLEADED l ) 02 REGULAR ( ) 03 PREMIUM (X 04 DIESEL ( ) 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( 1 INCHES ( ) CM e\) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 4( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( /i,02 SINGLE WALLED ( ) 03 LINED <br /> D. 01 CARBON STEEL ( ) 02 STAINLESS STEEL SX 03 FIBERGLASS l ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> f 1 06 ALUMINUM l ) 07 STEEL CLAD l 1 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />