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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> -F7- <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OONER <br /> NAME(C PPORATION,INDI DUAL OR PUBLIC ENCY) PUBLIC AGENCY ONLY <br /> - 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREE DO S CITY T <br /> SZIP <br /> -- <br /> II FACILITY _ <br /> T NAME <br /> DEALER/FOREMAN/SUPERVISOR <br /> FASI"STR AD ES NEARE T CROSS STR ET <br /> 1'- ` - <br /> '--- COUNT ZIP <br /> CITY <br /> MAILZN DDR S CITY STA ZIP <br /> 0 S <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> ® -- t ) 01 GASOLINE STATION 02 OTHER �(� <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP <br /> SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAPS: 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. ( O1 TANK ( ) 04 OTHER: CONTAINER NUMBER 6-33-1- <br /> B. <br /> 3j-B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED `\, UNKNOWN <br /> D. CONTAINER CAPACITY: ' GALLONS t ) UNKNOWN E. DOES THE CONTAINER STORE: t ) 01 WASTE 2 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? C, 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t ) 01 UNLEADED t ) 02 REGULAR ( ) 03 PREMIUM 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( D GAUGE ( D INCHES ( ) CM (>� UNKNOWN <br /> B. t ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 02 SINGLE WALLED ( ) 03 LINED <br /> 0. q 01 CARBON STEEL ( D 02 STAINLESS STEEL t ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE(' <br /> ( ) 06 ALUMINUM ( D 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE l D 10 NON-METALLIC <br /> ( ) 12 UNKNOWN t D 13 OTHER: <br /> "PAGE 1 <br /> HSC04-070185 <br />