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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (�) O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED t ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMEN"O ED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I 0 O N E R <br /> NAM O PORATION,INDIVI AL OR PUBLIC ENCY) PUBLIC AGENCY ONLY <br /> O1 FED ( ) 02 STATE ( ) 03 LOCAL <br /> $TREE AD RESS CITY STATE ZIP <br /> -- <br /> �I�I� FACILITY _ <br /> FFACII TY NAME u� DEALER/FOREMAN/SUPERVISOR <br /> ® NEAREST ROSS STREET <br /> ETRE ADORES <br /> COUNT ZIP _ <br /> CITY <br /> c <br /> MAIL AD RsSS CITY ST ZIP <br /> PHONE W/AREA CODE ry(p, <br /> OF BUSINESS ' ! - <br /> — ) 01 GASOLINE STATION (>,I02 OTHER L <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAPS' NAME(IAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAM£(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION _ <br /> A. (,�,,1-01 TANK ( ) 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( D UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? V D 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( D 03 PREMIUM (,5f-64 DIESEL ( ) 05 WASTE OIL ( D 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( D GAUGE t D INCHES ( ) CM (UNKNOWN <br /> B. ( D 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 2 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t ) 01 DOUBLE WALLED ( 02 SINGLE WALLED ( ) 03 LINED <br /> D. 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM l D 07 STEEL CLAD ( ) 08 BRONZE t D 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE I <br /> HSC04-070185 <br /> l <br />