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STATE ID NUMBER y` <br /> a' <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (`k 01 NEW PERMIT l 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED 1 i Q9 DELETE FROM FILE IND FEE) <br /> FF 1 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 04 MINOR CHANGE ING SURCHARGE) <br /> I, 0WNE'R" <br /> NAM! COP-ORATION. ,CIVVIIDULL OR PUBLIC �0qf NCY 1-11 � PUBLIC AGENCY ONLY <br /> 1 01 FED 1 1 02 STATE ;1:;Ip) 03 LOCAL <br /> SrR• AC'J •-"--����i-- CITY STATE z f oo. / 1 <br /> II. FACILITY <br /> 1 iFACILITY NAME r DEALE /F[ MENYSUPERVISOp <br /> STREET ACD'ESS Nl PPEST CROSS STREW <br /> `CITY <br /> COUNTY ZIP <br /> 9 S o <br /> APIA IATADDRESS I CIT STATE Z '�1�a <br /> `/`T41 _ <br /> bHQNsW,PA CODE Q2 TYPE OF BUSINESS <br /> ^'b$3 f 01 GASOLINE STATION l 1 02 OTHER ' <br /> t4L1Y0ER FF CONTAINE'S RURAI AREAS ONLY TOWNSHIP ---- RANGE - SECTION—_ <br /> i'. <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAl..EiLAST NAME FIRST) AND PHONE W AREA CODE J�NIGHTS.' NAMC LAST NAME FIRST) AND PHON W'APEA CODE <br /> ��=1188ole«.L-�-I R-a�.f � C800�y2/-7s�s <br /> Ft COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 TAtOC f 1 02 OTHER CONTAINER NUMBER <br /> 2- <br /> 5. <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLEDlqf�!Z( 1 UNKNOWN <br /> 0. COOTAINER CAPACITY: r GALLONS 11 IIM NOWH E. DOES THE CONTAINER STORE! I 1 01 WASTE (X 02 PRODUCT <br /> F. DOES THE CONTAINEFLITORE ROTOR VEHICLE FUEL OR WASTE OIL ? 1 S 1 ) 02 NO YES CHECK APPROPRIATE SO%l ES1' <br /> 1 _I 1 01_- UILEAOEO _ _ LAR 1 '4 03 PREMIUM 1 1 04 DIE L_1 1 05 WASTE OIL t� 06 OTHER <br /> i <br /> V CONTAINER CONSTRUCTION _ <br /> II`(A THICCNESS OF PRIMARY CONTAINMENT: 6,2-40 1 1 GAUGE ()Q RICHES ( 1 CM 1 1 UNKNOWN <br />( B. '( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) lel 0 AULTED 1 103 UNKNOWN <br /> +C. I ) 91 DOUBLE WALLEDSINGLE WALLED 1 1 03 LINED <br /> 0. 1� ARBON STEEL l ) 02 STAINLESS STEEL 1 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE l 1 OS CONCRETE <br /> ( 1 06 ALUMINUM l 1 07 STEEL CLAD l 1 00 BRONZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN 1 ) 13 OTHER: <br /> MSC04-Oi0185 "'PAGE 1 <br />