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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 101 NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> OON E R <br /> PUBLIC <br /> NAME(Coj�P;ORATION.INDIVIQ) AL OR PUBLIC A CY) A<1-01 AGENCY ONLY FED 02 STATE 03 LOCAL <br /> CITY STATE ZIP <br /> T <br /> _� A fDE <br /> Il FACILITY <br /> FAC.j. Tj NAME DEALER/FOREMAN/SUPERVISOR <br /> STRE ADD SS <br /> NEARES CROSS STRE T <br /> I <br /> ZIP <br /> COUN <br /> CITY S�n:kx <br /> e <br /> ZIP A [Ip <br /> CITY S T <br /> MAILI ADD V_o -,, <br /> T_ <br /> PHONE /AREA CODE ITYPE OF BUSINESS <br /> _L, ) 01 GASOLINE STATION 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE <br /> SECTION <br /> 111 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) 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 /> IV DESCRIPTION <br /> A. .CONTAINER NUMBEREINSTALt <br /> C. Y <br /> EMF NUMBER <br /> CONTAINER NUMBER /7 <br /> 01 TANK 04 OTHER- <br /> YEAR MFG: C. YEAR INSTALLED N<r-UNKNOWN <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> DOES THE CONT 01 WASTE (N 02 PRODUCT <br /> D. CONTAINER CAPACITY: _-2_CrV GALLONS UNKNOWN E. DOES THE CONTAINER STORE: <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 01 YES 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 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 (,"-4-UNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (-, 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ol DOUBLE WALLED 02 SINGLE WALLED 03 LINED <br /> ffD. Prf 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 /> UNKNOWN 13 OTHER' <br /> c )(O1 <br /> 2) i PAGE I <br /> HSC04-070185 <br />