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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND' STORAGETANK 1 <br /> 41'01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO-FEE) i <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT '" ( ) 08 MINOR CHANGE (NO;SURCHARGE) li <br /> I OWNER <br /> NAME(CORPORATION,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED t D 02 STATE ( ) 03 LOCAL_ <br /> STRREEjET�cA�DDRESS C�Y ST <br /> ATEZIP <br /> r <br /> II IFAFACI LITY <br /> iFACI ILI Y AME ' DEALER/FOREMEN/SUPERVI OR <br /> STREET ADDRESS NEAREST CROSS STREET <br /> Vi <br /> CITY couppy ZIP <br /> MAILING ADDRESS Q ( CITY ST TE ZIP <br /> fill <br /> PVN! W/A EA CODE TYPE OF BUSINESS <br /> (%A I GASOLINE STATION t ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND P ONE W/AREA CODE NIGHTS: NAME(LAST NAME F RST) NO PHONE W/AREA CODE <br /> 2-37S5 l S <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): /rj ) YEAR MFG:QeW C. YEAR INSTALLED (V)-UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: (✓TEAO1 WASTE t l 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ("--rl YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( l 01 UNLEADED t 102 REGULAR t ) 03 PREMIUM t D 04 DIESEL (0-05 WASTE OIL ( ) 06 OTHER —J <br /> V CONTAINER CONSTRUCTION <br /> f <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( ) INCHES ( ) CM (LD-VWNOWN <br /> I <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 0-�2 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 01 DOUBLE WALLED ( l 02 SINGLE WALLED .( ) 03 LINED <br /> -'I <br /> D. ( ) 01 CARBON STEEL t l 02 STAINLESS STEEL ( 0-n FIBERGLASS ( D 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( D 08 BRONZE ( ) 09 COMPOSITE t l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN t ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />