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c / STATE IO NUMBER A <br />c` <br />APPLICATION ^FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />I O1 NEW PERMIT ( 1 OS RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE°FROM FILE (NO FEE) <br />( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT — ( ) 08 MINOR CHANGE (NO SURCHARGED <br />I OWNER <br />NaME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) <br />STPEET ADDRESS <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />( ) 01 FEO ( ) 02 STATE ( 1 03 LOCAL <br />FACILITY NAME <br />OEALER/FOPEMEN/SUPEPVISOP <br />STPEET 400°ESS <br />NEAPEST <br />CROSS STPEET <br />CITY <br />COUNTY <br />ZIP <br />MAILING ADOPESS <br />CITY <br />STATE <br />ZIP <br />PHONE WACEA CODE <br />- - <br />TYPE <br />OF BUSINESS <br />01 GASOLINE STATION ( <br />D 02 OTHER <br />NUMBER CF CONTAINEVS <br />PUPAL AREAS <br />ONLY <br />TOWNSHIP <br />PANGS <br />SECTION <br />111 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAMEBLAST NAME FIPST) AND PHONE W/APER CODE 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 />01 TANK t-1 02 OTHER: <br />CONTAINER NUMBER <br />B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: I C. YEAR INSTALLEO ( ) UNKNOWN_ <br />0. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN JE. DOES THE CONTAINER STORE: ( 1 01 WASTE ()() 02 PRODUCT <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br />( 1 01 U'lLEADEO ( ) 02 REGULAR ( D 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL t)(06 OTHER j® <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PP.IMARY CONTAINMENT: t ) GAUGE ( INCHES ( 1 CM ( ) UNKNOWN <br />- - --- -- - — - — --- a ---- --- --- - — --- -.. --- --- <br />----------- ------ <br />8. ( ► 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 02 NON -VAULTED 1 ) 03 UNKNOWN <br />IC. ( 1 01 DOUBLE WILLED 06 02 SINGLE WALLED t ► 03 LINED <br />(0. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL ()(l 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />t 1 06 ALUMINUM ( ) 07 STEEL CLAD ( i 08 BRONZE ( i 09 COMPOSITE ( 1 10 NON-METALLIC <br />( l 12 UNKNOWN ( ) 13 OTHER: <br />HSC04-070185 PAGE 1 <br />