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STATE 10 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> F( 01 NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 06 AMENIJED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> OPINE R <br /> PUBLIC AGENCY ONLY <br /> NAME(COPPORATION,INDI%flgUAL OR PUBLI AGENCY) (T ol FED <br /> 0 C <br /> 01 2 STATE 03 LOCAL <br /> TCI <br /> SSTAA <br /> TREE <br /> —Ty L <br /> TP <br /> _�; ADDP IOS-le <br /> yy <br /> FACILITY <br /> 1FACITY NAME DEALER/FOREMAN/SUPERVISOR <br /> A-L <br /> A I <br /> STREE ADORES NEARS" CROSS STREET <br /> d g5ii r <br /> COUNT ZIP <br /> CITY <br /> MAILS ADDRESS <br /> CITY STATE zip <br /> >19 i If <br /> tk L-4L-T <br /> 'USINE-S <br /> TYPE OF GASOLINE STATION Q0 0? OT <br /> 01 GA <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 9�&,I- ( ) 01 GASOLINE STATION 0() 0? OTHER <br /> &4// <br /> S ONLY <br /> NUMBER OF CONTAINERS RURAL AREA TOWNSHIP <br /> RANGE SECTION <br /> 111 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME <br /> (LAST NAME FIRST) AND PHONE W/APEA 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 /> CONTAINER NUMBER <br /> A. Pj 01 TAW 04 OTHER= <br /> B. MANUFACTURER (IF APPROPRIATE)- <br /> YEAR MFG: C. YEAR INSTALLED 0<1 UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS UNKNOWN E. DOES THE CONTAINER STORE' 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (-Ad-01 YES 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 01 UNLEADED 02 REGULAR 03 PREMIUM ( 04 DIESEL 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM (k"NKNOWN <br /> B. t l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) V-02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 01 DOUBLE WALLED [XI'02 SINGLE WALLED 03 LINED <br /> 0. 06 01 CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> ) 06 ALUMINUM 07 STEEL CLAD 08 BRONZE 09 COMPOSITE 10 NON-METALLIC <br /> 12 UNKNOWN 13 OTHER: PAGE 1 <br /> HSC04-070185 <br />