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n 8 <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> F01 NEW PERMIT ( ) 05 RENEWEO PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMEKDED PERMIT ( ) 08 MINOR CHANGE tNO SURCHARGE)) <br /> I O PJ N E R <br /> NAME(CO PORATION.INOIVI , AL OR PUBLI GENCY) PUBLIC AGENCY ONLY <br /> ( O1 FED ( ) 02 STATE t D 03 LOCAL <br /> CITY STAT ZIP <br /> STPEA ADDRESS <br /> r -- <br /> II FACILITY - <br /> FACIT NAME _ DEALER/FOREMAN/SUPERVISOR <br /> Y 4 <br /> [MAILIN"DoR.SS <br /> EET ADORE I HEAVES CROSS STRE T .� <br /> _ �. \ \ <br /> COON��pa77��"'-�-��� ZIP <br /> Y 1 j !c <br /> CITY STATE PSP <br /> 17 Tk <br /> ONE W/AREA CODE v TYPE OF BUSINESS ` t <br /> %� f ( ) 00 GASOLINE STATION t 02 OTHER e L <br /> �o <br /> NUMBER OF CONTAINERS <br /> RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> F <br /> : NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(IAST NAME FIRSTD AND PHONE W/AR-cA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( i TAMC ( ) 04 OTHER: CONTAINER NUMBER <B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( NOWN <br /> D. CONTAINER CAPACITY: GALLONS UNKNOWN E. DOES THE CONTAINER STORE: _ 1 WASTE t ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? t. O1 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t D 01 UNLEADED ( ) 02 REGULAR t ) 03 PREMIUM ( ) 04 DIESEL Lk-05 WASTE OIL ( D 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM QV UNKNOWN <br /> B. t D 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 02 NON—VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (,!51 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL t D 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( D 07 STEEL CLAD t ) 08 BRONZE ( ) 09 COMPOSITE t ) 10 NON—METALLIC <br /> 12 UNKNOW)( ( ) 13 OTHER: _ <br /> PAGE 1 <br /> HSC04-070185 <br />