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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t ) 01 NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 3 02 CONDITIONAL PERMIT ( ) 06 AMEN'OED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> t ) <br /> I OPINE <br /> NAME( ORPORATION,INDIVI UAl OR PUBLI AGENCY) [P(! <br /> BLIC AGENCY ONLY <br /> <01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> CITY STAT Zpne— : <br /> IP <br /> STRE AD RESS -- <br /> II FACILITY <br /> �FACIL TY NAME DEALER/FOREMAN/SUPERVISOR <br /> NEAREST CROSS ST EET <br /> STREE AD I n ES - -` <br /> 9 <br /> e_A r <br /> C 0 U'um Y, Z%P <br /> STA E <br /> CITY <br /> m r o IP <br /> -- <br /> CITY Z <br /> MAILI AD RESS <br /> !3 (' T_ <br /> PHONE W/AREA CODE _ TYPE OF BUSINESS - <br /> 01 GASOLINE STATION (A) 02 OTHER /1t <br /> NUMBER OF CONTAINERS <br /> RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEQLAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS? NAME(LAST NAME FIRST) AND PHONE W/ARrA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> Ili DESCRIPTION <br /> A. ( O1 TANK t ) 04 OTHER= CONTAINER NUMBER "L <br /> B. MANUFACTURER (IF APPROPRIATE)- YEAR MFG- C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY- /l S—GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE- ( 101 WASTE (>)-02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 01 YES f ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)- <br /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR t ) 03 PREMIUM t 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT- ( ) GAUGE ( 3 INCHES ( ) CM (kf UNKNOWN <br /> B. ( 101 VAULTED (LOCATED IN AN UNDERGROUND VAULT) C>er 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED (Xf 02 SINGLE WALLED f ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 105 CONCRETE <br /> ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (kj12 UNKNOWN ( ) 13 OTHER- <br /> PAGE 1 <br /> HSC04-070185 <br />