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7A_7�% « <br />STATE IO NUMBER <br />APPLICATION a FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />1 O1 NEW PERMIT ( 1 05 RENEWED PERMIT t 1 07 TANK CLOSED ( 1 09 OELETE FROM FILE (NO FEEI <br />08 MINOR CHANGE lN0 SURCHARGE) <br />1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT 1 1 <br />[STREET <br />r♦ I. T I T T V <br />TTT 3L unlla GMFRr.FNrV r_nNTACT PERSON <br />AYS: HAr.E(LAST NAME <br />FIRST) <br />AND PHONE <br />W/APER CODE <br />)AGILITY NAME <br />J� <br />(/ <br />DE R/►OPCMEM'SVPERVISOP <br />//`� <br />STREET A002S <br />7d <br />NEAREST CROSS S PEET <br />CITY <br />S 7m/v <br />(/��{. <br />- IV <br />COUNTY (� <br />✓ r� <br />IIP��r C/,�//� <br />MAILING AOOPESS <br />f�U� <br />CITY <br />STAT ZIP <br />a d •�/rU�wo� <br />PHONE W/AvzA CODE <br />TYPE OF BUSINESS <br />1 01 GASOLINE <br />STATION ((l 02 OTHER I <br />NU(:BER CF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNS1iIP <br />TANGE <br />SCCTION <br />TTT 3L unlla GMFRr.FNrV r_nNTACT PERSON <br />AYS: HAr.E(LAST NAME <br />FIRST) <br />AND PHONE <br />W/APER CODE <br />NIGHTS: NAME(IAST NAME FIRST) AND PHONE W/AREA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. 1 O1 TANK( ) 02 OTHER: CONTAINER NUMBER <br />FB. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br />0. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN IE. DOES THE CONTAINER STORE: ( 1 01 WASTE ( ) 02 PRODUCT <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WAS E.OIL ' ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />,.l Inti rAncn 1 1 n� Goin AP ( 1 D3 PREMIUM (X04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />-V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES ( 1 CM ( ) UNKNOWN <br />B. ( 1 01 VAULTED (LOCATED IPI AN UNDERGROUND VAULT) ( 1 02 NON -VAULTED 1 ) 03 UNKNOWN <br />C. ( 1 01 DOUBLE WALLED ) 02 SINGLE WALLED ( 1 03 LINED <br />D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 105 CONCRETE <br />( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE (.1 10 NON-METALLIC <br />12 UNKNOWN (XI 13 OTHER:w�ni��L✓��, <br />a �— <br />HSC04-070185 <br />PAGE 1. <br />