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(til 5 tin �� Vlvr SfcC� (vr�h n>*al <br /> STATE ID NUMBER <br /> // APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( �O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( l 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE)) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP.PORATZON,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> t L GQ ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> ep <br /> STREET DRESS Co STATE ZIP <br /> II FACILITY <br /> FACILITY N ME DEALER/FOREMEN/SUPERVISOR <br /> S 69(L— <br /> STREET ADDRESS n _ NEAREST ROSS STREET <br /> OO V V �L IV i� GT. W�r=�' L,�-j - <br /> CITY COU TY '� ZIP <br /> MAILING ADDRESS CITY STATE ZIP <br /> S <br /> P- A CODE TYPE OF BUSINESS <br /> � (0-11G� ( ASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> ID <br /> II24 HOUR EMERGENCY CONTACT PERSON <br /> AYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: 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. ( TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): �w�v S Cd�N YEAR MFG:q E:W C. YEAR INSTALLED (UNKNOWN <br /> D. CONTAINER CAPACITY: 'jS0 GALLONS t ) UNKNOWN I E. DOES THE CONTAINER STORE: ( EAI WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> -(-1 01 UNLEADED ( ) 02 REGULAR ( l 03 PREMIUM ( l 04 DIESEL (L]-85 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> —�I <br /> I <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (L-k- F NOWN <br /> i <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 4-1-2 NON-VAULTED ( ) 03 UNKNOWN <br /> i <br /> C. (0--01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED ` <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( Q-n FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 110 NON-METALLIC i <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />