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f <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 4. ( ) ( D 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> C-14 01 NEW PERMIT 05 RENEWED PERMIT <br /> t D 02 CONDITIONAL PERMIT t ) 06 AMENDED PERMIT l ) 08 MINOR CHANGE iN0 SURCHARGED <br /> I OWNER <br /> PUBLIC AGENCY ONLY <br /> AMEtCORPORATION,INO VIDUAI OR PUB AGENc ) O1 FED t ) 02 STATE. t ) 03 LOCAL <br /> f oo CITY STA ZIP <br /> $TREE --)ADDq S <br /> OA <br /> --I I FACILITY I' <br /> DEALER/FOREMAN/SUPERVISOR <br /> FACILITY AME <br /> NEARESI CROSS STR ET <br /> ;SS <br /> S - <br /> COUNT ZIP <br /> 3,6,5;t . .E, _ <br /> CITY STATE ZIP <br /> L r� <br /> TYPE OF BUSINESS f))` <br /> cooE _ ( ) <br /> 01 GASOLINE STATION411 <br /> t 02 OTHER ( � i ( <br /> NUMBER OP CONTAINERS <br /> RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 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. t O1 TANK ( l 04 OTNER: <br /> CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATED= YEAR MFG: C. YEAR INSTALLED <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN [E.:DDO:ES:;TH:E:C:OH�TAINER STORE: ( D O1 WASTE 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 /> t ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM 04 DIESEL t D 05 WASTE QIl t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE t ) INCHES ( ) CM NOW" <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> E <br /> DOUBLE WALLED (,4 02 SINGLE WALLED t ) 03 LINED <br /> CARBON 06 ALUMINUM STAINLESS <br /> STEEL <br /> 08( 03 BRONZEFIBEDG09SCOMPOSITE POLYVINYL( 1NLORIDEMETALLIC( ) 05 CONCRETE <br /> 2 UNKNOWN ( D 13 OTHER: <br /> PAGE 1 <br /> HSC04-07,185 <br />