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a STATE IO NUMBER <br />APPLICATION ,FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />t 01 NEW PERMIT ( I OS RENEWED PERMIT ( 1 07 TANK CLOSED ( D 09 OELET£ FROM FILE (NO FEE g <br />t ) 02 COP(DITIONAL PERMIT t ) 06 AMENDED PERMIT t ) 08 MINOR CHANGE (NO SURCHARGE)_— <br />I OWNER <br />NAI'E(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) <br />STREET ACnRESS <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />( 1 <br />01 FED ( l 02 STATE ( ) 03 LOCAL <br />CITY STATE ZIP <br />FACILITY NAME <br />DEALER/f OPEMEN/SUPERVISOP <br />Arco <br />STREET ACC°ESS <br />NEAREST <br />CROSS STREET <br />CITY <br />COUNTY <br />ZIP <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />PNOAE W,AVEA CODE <br />TYPE Of BUSINESS <br />— — <br />) 01 GASOLINE <br />STATION ( <br />1 02 OTHER <br />v <br />NUMBER Of CONTAINERS <br />_— <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />E3'NAME(IAST NAME FIRST) AND PHONE W/ARlA COOS NIGHTS: NAME(LAST NAME FIRST) -ANO -PHONE W�AREA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />Lv <br />1 01 TAt?K ( 1 02 OTHER: <br />CONTAINER NUMBER ' , <br />B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1167 ( ) UNKNOWN <br />0_COPITAINER CAPACITY: ,/ _ GALLONS t 1 UMCNOWN E. GOES THE CONTAINER STORE: ( 1 01 WASTE 06 02 PRODUCT _`— <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />_ ( ) 01 U,ILEADED ( 1 02 REGULAR ( D-03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL lV 06OTHER <br />V CONTAINER CONSTRUCTION <br />A. THICKtIESS OF PP,IMARY CONTAINMENT: t ) GAUGE ( INCHES ( 1 CM l 1 UNKNOWN <br />B. ( ) 01 VAULTED (LOCATED IN AN UNOERGROUNO VAULT) ( 1 02 NON—VAULTED ( ) 03 UNKNOWN <br />'C. ( 1 01 DOUBLE W'LLEO (V) 02 SINGLE WALLED ( ) 03 LINED <br />D. ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( i 08 BRONZE ( ) 09 COMPOSITE ( 110 NON—METALLIC <br />( 1 12 UNKNOWN ( ) 13 OTHER: <br />HSC04-0 0185 <br />PAGE 1 <br />