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STATE YD NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t 1 O1 NEW PERMIT t ) 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 OWNER - -T <br /> NAME(C PPORATION.INDIV DUAL OR PUBLEC ENCY) PUBLIC AGENCY ONLY <br /> - 01 FED ( ) 02 STATE t 103 LOCAL <br /> ��AD SS CZTY STA ZIP <br /> II FACILITY <br /> CIL (DAME DEALER/FOREMAN/SUPERVISOR <br /> STRRESNEARE CROSS S RESTf <br /> E A S -- <br /> / 1r of <br /> ' COUNT 9 ,..,.�._..._. r ZIP <br /> CITY <br /> MAlLjX9 A FSS CITY STATE ZIP <br /> PHONE W/AREA CODE TYPE OF BUSINESS w.q <br /> ( D O1 GASOLINE STATION t 02 OTHER 6 t' r <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST <br /> ) 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. 01 TANK ( ) 04 OTHER: CONTAINER NUMBER &13 <br /> B. MANUFACTURER (IF APPROPRIATE)= YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS�- K�N �E�. DOES THE CONTAINER STORE: ( D 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (>fj 01 YES ( D 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t D 01 UNLEADED t ) 02 REGULAR ( D 03 PREMIUM 04 DIESEL W 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE t D INCHES ( ) CM t>%I UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) W 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t ) 01 DOUBLE WALLED t>0 02 SINGLE WALLED ( D 03 LINED <br /> D. O1 CARBON STEEL ( D 02 STAINLESS STEEL t l 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE t ) 05 C014CRETE <br /> t ) 06 ALUMINUM ( ) 07 STEEL CLAD t D 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOW)( ( ) 13 OTHER: <br /> -- PAGE 1 <br /> HSC04-070185 <br />