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d <br />a STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />L)) 01 NEW PERMIT ( D 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />r T 02 CONDITIONAL PERMIT ( D 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br />I OWNER l� <br />NAME(COPPORA.TION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />( ) 01 FED ( D 02 STATE ( D 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />TT FACILITY <br />FACILITY NAME <br />DEALER/FCREMEN/SUPERVISOR <br />STREET ADDRESS <br />CONTAINER <br />NEAREST CROSS STREET <br />CITY <br />A. <br />COUNTY <br />ZIP <br />MAILING ADDRESS <br />) 03 UNKNOWN <br />CITY <br />STATE <br />ZIP <br />PHONE W"APEA CODE <br />YEAR MFG:/?f6C. <br />TYPE OF BUSINESS <br />01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />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 />V CONTAINER CONSTRUCTION <br />CONTAINER <br />NUMBER <br />t ) GAUGE ( D INCHES ( <br />A. <br />l 01 TANK ( ) 02 <br />OTHER: <br />IN AN UNDERGROUND VAULT) ( 02 NON—VAULTED ( <br />) 03 UNKNOWN <br />B. <br />MANUFACTURER (IF APPROPRIATE): r2xr-s <br />YEAR MFG:/?f6C. <br />C. Y) 01 <br />YEAR INSTALLED <br />2006( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: <br />GALLONS ( ) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />1 01 WASTE Y � <br />02 PRODUCT <br />F. <br />DOES THE CONTAINER <br />STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (h'1 01 YES ( ) 02 NO <br />IF YES CHECK APPROPRIATE BOX(ES): <br />BRONZE ( ) 09 COMPOSITE <br />( ) 01 UNLEADED ( <br />) 02 REGULAR Y� 03 PREMIUM t <br />) 04 DIESEL ( ) 05 WASTE OIL <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />HSC04-0 0185 <br />PAGE 1 <br />A. THICKNESS OF PRIMARY CONTAINMENT: <br />t ) GAUGE ( D INCHES ( <br />) CM ( ) UNKNOWN <br />B. ( ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) ( 02 NON—VAULTED ( <br />) 03 UNKNOWN <br />C. Y) 01 <br />DOUBLE WALLED ( <br />) 02 SINGLE WALLED ( <br />) 03 LINED <br />D. ( ) 01 <br />CARBON STEEL ( <br />) 02 STAINLESS STEEL <br />03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE ( D 05 CONCRETE <br />( ) <br />06 ALUMINUM ( ) <br />07 STEEL CLAD ( 1 08 <br />BRONZE ( ) 09 COMPOSITE <br />( ) 10 NON—METALLIC <br />( D 12 <br />UNKNOWN ( ) 13 <br />OTHER: <br />HSC04-0 0185 <br />PAGE 1 <br />