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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t,>!r'01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> t 102 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OvlNER <br /> --- <br /> NAME(COPPORATION,INDIV DUAL OR PUB AGEN Yl PUBLIC AGENCY ONLY <br /> r --- ( 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> $TRE , ADD ESS STATE <br /> CITY ITP <br /> (I�I� FACILITY <br /> �FACILIT NAMEA�?f- -e DEALER/FOREMAN/SUPERVISOR <br /> r� \� <br /> STREET DDRE NEARESCROSS SIRE T - <br /> CITY ZIP <br /> MAXIMS CITY ST T ZIP <br /> l - <br /> PHONE W/AREA CODE FTYPF OF BUSINESS <br /> )�� ) 01 GASOLINE STATION (>,"Z OTHER y �1 <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/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TANK ( l 04 OTHER: COP(TAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED NOWN <br /> D. CONTAINER CAPACITY: / ,,GALLONS ( D UNKNOWN E. DOES THE CONTAINER STORE: 1 WASTE t ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ^-T-01 YES ( D 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( D 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM t ) 04 DIESEL 5 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM t14—UNKNOWN <br /> B. 6 ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (may 02 SINGLE WALLED ( 1 03 LINED <br /> ff <br /> 01 CARBON STEEL ( ) 02 STAINLESS STEEL t D 03 FIBERGLASS t D 04 POLYVINYL CHLORIDE t ) 05 CONCRETE <br /> ) 06 ALUMINUM ( ) 07 STEEL CLAD t l 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE I <br /> HSC04-070185 ° <br />