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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> FO1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TAM( CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ) 02 CONDITIONAL PERMIT ( ) 06 AMEND ED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I DONE <br /> NAME( RPORATION.INDZ IDUAL OR PUBLIC G£NCY) PUBLIC AGENCY ONLY <br /> —— (-V-01 FED t ) 02 STATE t D 03 LOCAL <br /> CITY ,_j � STATE ZIP <br /> STREE ADD ESS (7 <br /> II FACILITY <br /> ZAAE DEALER/FOREMAN/SUPERVISOR <br /> SNEARES CROSS STR ET <br /> COU ( /` ZIP ,i�C3 _ h �! G CITY STA ZIPE S CODE TYPE OF BUSINESS <br /> ( O1 GASOLINE STATION 02 OTHER c 6 >rNTAINERS / RURAI AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAPS: NAME(LAST 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. 01 TAMC ( ) 04 OTHER: <br /> CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED p-4 UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( 11NK <br /> UNOWN E. DOES THE CONTAINER STORE: 01 WASTE t ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( D 01 YES t 2 NO If YES CHECK APPROPRIATE BOX(ES): <br /> t D 01 UNLEADED ( D 02 REGULAR ( ) 03 PREMIUM t ) 04 DIESEL t ) 05 WASTE OIL t D 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM NKNOWN <br /> B. { ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (,-0'02 NON—VAULTED ( ) 03 UNKNOWN <br /> C. t ) 01 DOUBLE WALLED 02 SINGLE WALLED ( D 03 LINED <br /> =(N4�'01STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> INUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE t ) 10 NON—METALLIC <br /> t ) 13 OTHER <br /> PAGE 1 <br /> HSC04-070185 <br />