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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> [E( ) 1 NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED09 DELETE FROM FILE (NO FEE) <br /> 2 CONDITIONAL PERMIT t D 06 AMEND ED PERMIT ( D 08 MINOR CHANGE (NO SURCHARGE) <br /> Y OONER --- - - -, - <br /> -- - PUBLIC AGENCY ONLY <br /> NAME(COPPORATION,INDIV DUAL OR PUBLIC AGENCY) (1,4'"01 FED ( ) 02 STATE ( D 03 LOCAL <br /> CITY STAB, ZIP <br /> STREET OD ESS -- --- - r <br /> FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> STREET DORE S NEARS T`CROSS STR ET <br /> war <br /> CITY COUN ZIP . , <br /> CITY ST T YIP <br /> MAILYN DDRE S <br /> i > <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> fNh <br /> _-��; t ) 01 GASOLINE STATION ( 02 OTHER )�( <br /> NUMBER Or L'Laped­ <br /> F CONTAINERS <br /> RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAPS: 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 ( D 04 OTHER: CONTAINER NUMBER <br /> rDOES <br /> CTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> NER CAPACITY: 1 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE 02 PRODUCT <br /> HE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 01 YES ( D 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM 04 DIESEL ( D 05 WASTE OIL t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( D GAUGE ( ) INCHES ( ) CM 4,i,4 UNKNOWN <br /> B. t ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) W 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. i ) 01 DOUBLE WALLED ( 02 SINGLE WALLED ( D 03 LINED <br /> D. 01 CARBON STEEL ( D 02 STAINLESS STEEL ( ) 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( D 06 ALUMINUM ( D 07 STEEL CLAD t ) 08 BRONZE t ) 09 COMPOSITE l ) 10 NON-METALLIC <br /> ( ) 12 UNKNOW)( i 1 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />