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REPROPUCK42 AT ) NT EXPENSE f <br /> i. <br /> STATE ID NUMBER <br /> APPLICATION `FOR PERMIT TO OPERATE UNDERGROUND -STORAGE- TANK <br /> -t D <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( D 09 DELETE FROM FILE (NO FEE) <br /> t 1 02 CONDITIONAL PERMIT t D 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGED <br /> OWNER <br /> ----- -- -- - <br /> arEtCOPPORATION,INDIVIDUAL OR FUBLIC.AGENCY) IC AGENCY ONLY <br /> 01 FED ( D 02 STATE ( ) 03 LOCAL <br /> WEET oCI—RE=5 — fs^ —` CITY STATE ZIP <br /> V <br /> FACILITY <br /> CILITY NA—.E DEALER/FOREMEN/SUPERVISOR <br /> FEET ACO'ESS NEAREST CROSS STREET <br /> COUNTY ZIP <br /> ILING ACOPESS CITY STATE ZIP <br /> OKE WlArEA CODE TYPE OF BUSYNESS <br /> ( D <br /> 01 GASOLINE STATION ( ) 02 OTHER <br /> :'BER CF CONTAINEPS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> ' I HOUR EMERGENCY CONTACT PERSON <br /> 'S: NAtlE( LA.ST NAME FIPST) 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 /> DESCRIPTION ®/ <br /> (\_.1-01 TANK t ) 02 OTHER: CONTAINER NUMBER ( ' <br /> MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( D UNKNOWN <br /> CONTAINER CAPACITY: GALLONS t ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ) 02 PRODUCT <br /> DOES THE CONTAINER 5TORL MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM K 04 DIESEL t D 05 WASTE OIL ( ) 06 OTHER <br /> CONTAINER CONSTRUCTION <br /> THICKNESS OF PP.IMARY CONTAINMENT: t ) GAUGE ( l INCHES ( ) CM ( UDOCNOWN <br /> t ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON—VAULTED ) 03 UNKNOWN <br /> '( 1 O1 DOUBLE WILLED ) 02 SINGLE WALLED ( ) 03 LINED <br /> M01CARBON STEEL ( J 02 STAINLESS STEEL ( D 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ). 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON—METALLIC <br /> t ) 12 UNKNOWN ( D 13 OTHER: <br /> :04-070105 PAGE 1 <br />