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.. <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (x1.01 NEW PERMIT ( 1 05 RENEWED PERMIT f 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEET <br /> fPT 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT t ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME) `:rATAON. ivxOUAI oR Pv Lic AaENcn ( 1LIC AGENCY ONLY <br /> `iT- t J l ) Ol AFEDGE ( l 02 STATE ( 1 03 LOCAL <br /> STREET AD^.R SS CIT STATE ZIP <br /> 40 l(/ YO <br /> II FACILITY <br /> FACILITY NAY, DEALER/FOPEMENISUPERVISOR <br /> CAN jell(bkEz <br /> 1 <br /> YTREET AOL-ESS NEAREST CROSS STREET <br /> ! - <br /> CITY COUNTY` ZIP <br /> -� 7 GCj <br /> MAILING ADOP SS CITY 6 TE_ ZIP <br /> z3 7 Ta C'T] <br /> I PHONE W/AREA CODE TYPE OF BUSINESS <br /> ( 1 Ol GASOLINE STATION 20 02 OTHER FOU( <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1.. <br /> : II 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAY,EI LAST NA E FIRST) AND PHONE W/APEA CODE NI NTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> � ✓�Ll`�01� �9"�i at7l <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. t.�) 01 TANK ( 1 02 OTHER: CONTAINER NUMBERZ <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1Z,) 01 WASTE 1 ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? lYcL 01 YES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> 1 1 01 UNLEADED ( ) 02 REGULAR 1 ) 03 PREMIUM t ) 04 DIE EL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES l 1 CM _V UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) [ 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED t ) 02 SINGLE WALLED 1 ) 03 LINED <br /> 0. 1 1 01 CARBON STEEL f 1 02 STAINLESS STEEL 1 / 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM ( 1 07 STEEL CLAD l 1 08 BRONZE l 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 12 UNDCNOWN ( l 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> i <br />