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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> rOl NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> 02 CONDITIONAL PERMIT 06 AMENOED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I DONE <br /> C AGENCY) PUBLIC AGENCY ONLY <br /> (-N4-01 FED 02 STATE 03 LOCAL <br /> ITY STATE ZIP <br /> STREET ADDRESS <br /> II FACILITY <br /> IFACI�A;Y I NAME VIN <br /> EET <br /> TR <br /> CITY coy;Axy ZIP <br /> STATE ZIP <br /> MAIL CITY <br /> Ile �_krc <br /> TE <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION <br /> NUMBER OF CONTAINERS TOWNSHIP ]RANGE SECTION <br /> PUPAL AREAS ONLY <br /> 111 24 HOUR EMERGENCY CONTACT PERSON <br /> FDAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CCOE 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 /> CONTAINER NUMBER <br /> A. 0<f"01 TANK 04 OTHER- ONTA NER BER <br /> YEAR MFG_ C_ YEAR INSTA L LED <br /> B. MANUFACTURER (IF APPROPRIATE)- YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: /6M GALLONS UNKNOWN E. DOES THE CONTAINER STORE: 01 WASTE KI 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 CA-T 04 DIESEL 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM (,yl UNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Pkj 02 NON-VAULTED ( ) 03 UNKNOWNC. 01 DOUBLE WALLED (N<02 SINGLE WALLED 03 LINED <br /> 05 CONCRETE <br /> 0. P<f 01 CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS 04 POLYVINYL CHLORIDE <br /> 06 ALUMINUM 07 STEEL CLAD 08 BRONZE 09 COMPOSITE 10 NON-METALLIC <br /> UNKNOWN 13 OTHER: PAGE I <br /> � oycu*-oruzas <br />