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A <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> F(�)dl O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 102 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OPINE <br /> NAME( ORPORATION>INDIV UAL OR PUBLICAGENCY) PUBLIC AGENCY ONLY <br /> 1 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET D - CITY g STATE ZIP <br /> ��� <br /> II FACILITY <br /> 'FACIL NAME DEALER/FOREM.AN/SUPERVISOR <br /> STREET DR SS NEART EET <br /> J i COON ZIP _ <br /> CITY ( <br /> _ `If- --- <br /> CITY STATE ZIP <br /> MAILIN DD S �. r //,Lp►" <br /> PHONE W/AREA CODE TYPE OF BUSINESS t <br /> q_ =.UP4L <br /> ( ) 01 GASOLINE STATION ( 02 OTHER y�LNUMBER OF CONTAINERS REASONLY : 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. t 01 TANK ( ) 04 OTHER: EMFG: c. <br /> UMBER <br /> B. MANUFACTURER (IF APPROPRIATE)- YEAR EAR INSTALLED NOWN <br /> D. CONTAINER CAPACITY: -ybVZP GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES t ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR ( 1 03 PREMIUM 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION - <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 3 INCHES ( ) CM (-UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t ) Ol DOUBLE WALLED USS 02 SINGLE WALLED ( ) 03 LINED _ <br /> 0. O1 CARBON STEEL ( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD i ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br /> .rY <br />