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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> )F 01 NEW PERMIT 05 RENEWED PERMIT C 07 TANK CLOSED 09 DELETE FROM FILE (NO FEE) <br /> W <br /> 0 O� C 08 MINOR CHANGE (NO SURCHARGE) <br /> 2 CONDITIONAL PERMIT 06 AMENDED PERMIT <br /> OON E R <br /> NAME(COPPORATL;ION,IND VIDUAL 0 4LIC AGENCY) (PUBLIC AGENCY ONLY <br /> 0Q-01 FED 02 STATE ( 1 03 LOCAL <br /> sAa Pe m CI STA E ZIP <br /> STPEEJ,ADOP SS Tj-oSkt-o 3?1 <br /> [II FACILITYFACILITY NAME <br /> DEALER/FOREMAN/SUPERVISOR <br /> I <br /> Arm_v �e <br /> I <br /> SIRE AVRESSpd NEAREST CROSS QEET <br /> � 41, <br /> Y; <br /> CITY <br /> COUNTY <br /> ZIP' SJo <br /> MAILIPADDS CITY <br /> ZIP <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> ( ) 01 GASOLINE STATION (,\l 02 OTHER <br /> NUMBER OF CONTAINERS <br /> RURAL AREAS ONLY TOWNSHIP RANGE <br /> SECTION <br /> 111 24 HOUR EMERGENCY CONTACT PERSON <br /> NI HTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> 2-0J-qi 2-- x,10 <br /> COMPLETE <br /> 21000MPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> CONTAINER ER <br /> NUMB <br /> A. P<f 01 TAW 04 OTHER CONTAINER NUMBER <br /> NKNOWN <br /> B. MANUFACTURER (IF APPROPRIATE)* YEAR MFG: C. YEAR INSTALLED) ±%:-:j1-�UWNOWN <br /> 0. CONTAINER CAPACITY: �or) GALLONS UNKNOWN E. DOES THE CONTAINER STORE: 01 WASTE ( .4-02 PRODUCT <br /> )DES THE CC <br /> ";1' <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 01 YES 02 NO IF YES CHECK APPROPRIATWEBOXES): <br /> 01 UNLEADED 02 REGULAR 03 PREMIUM 00 04 DIESEL 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t GAUGE INCHES ( ) CM 0<1 UNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (>,Lr'02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 01 DOUBLE WALLED (\1' 02 SINGLE WALLED 03 LINED <br /> D. 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* <br /> PAGE I <br /> HSC04-070185 <br />