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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT t 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INCIVIDU4L OR FUSLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED t ) 02 STATE ( D 03 LOCAL <br /> STREET AC^RESS CITY STATE FZIP <br /> II FACILITY <br /> FACILITY NAME q_ DEALER/FOPEMEN/SUPERVISOR <br /> J s_ <br /> STREET A D^ESS NEAREST CROSS STREET <br /> Vin¢ AA - <br /> CITY COUNTY ZIP <br /> MAILING ADDRESS CITY STATE ZIP <br /> PHONE W,AcE4 CODE TYPE OF BUSINESS <br /> — ( ) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMEtIAST NAME FIRST) AND PHONE WiAREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE) YEAR MFG fC.::Y:E:A;:lNSTALLED ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: , GALLONS t 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ) 02 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 ( ) 04 DIESEL ( 105 WASTE OIL 06 OTHER ( L ®lL <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( D INCHES ( ) CM �,+ UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) kf 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 02 SINGLE WALLED ( D 03 LINED <br /> D. 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( D 07 STEEL CLAD ( D 08 BRONZE ( l 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( l 13 OTHER: <br /> HSC04-00185 PAGE 1 <br />