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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 0<'D1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TAMC CLOSED ( ) 09 DELETE FROM FILE (NO FEED <br /> ( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I 0 O N E R v-- -- --T-- <br /> NAME(COPPORATION.INDIVI AL OR PUBLIC 01 <br /> GENCY) PUBLAGENCY ONLY <br /> — —— ( O1 FED ( ) 02 STATE ( D 03 LOCAL <br /> CITY �TA�TWEJZlx PSTRE ADD S <br /> (I�I� <br /> FACILITY <br /> 1FAC;J-tTf NAME DEALER/FOREMAN/SUPERVISOR <br /> [MAILI <br /> E ADD E S NEARE T CROSS STR ET <br /> r _-'-- COUNTY ® ` ` ZIP _ <br /> Y S <br /> ADD ESS CITY ST ZIP <br /> ONE W/AREA CODE TYPE OF BUSINESS <br /> _ l ( ) O1 GASOLINE STATION ty9 02 07NER t t <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: 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. t 1 TANK ( D 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: 1�51_ GALLONS ( 11UNKNOWN E. DOES THE CONTAINER STORE: ( 101 WASTE (-N"Z PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM t 4 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( D GAUGE ( D INCHES ( ) CM NKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t ) 01 DOUBLE WALLED 02 SINGLE WALLED (_D 03 LINED <br /> D. (>eK01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( D 05 COt4CRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE l ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN t ) 13 OTHER: <br /> -- PAGE 1 <br /> HSC04-070185 <br />