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STATE IO 1.'UM"EF' <br /> APPLICATION FOR PERMIT TO OPL RATE UNDERGROUND SIOP.AGE TA14K <br /> C4) 01 NEW PFRHIT I ) 05 RENEWED FLRMIT ( ) 07 TMX CLOSED ( ) 09 DELETL FPOM FILE (NO FEE) <br /> ( , 02 CO::OITIONAL PERMIT t ) 06 AM'ENOEO PERY,I1 ( ) OD MINOR CHANGE IND SURCHARGE) <br /> 7 OiINER <br /> f-AME( 3CN,INDIVIDUAL OR PUBLIC AG"'Y) PUBLIC ASENC( ONLY <br /> &kLb-1�1-I e,,,,,„„ (^D L. �,p - ( 1 01 PEG f ) 0'[ STATE 1 1 03 LOCAL <br /> I S`PE''T ADDRESS CITY - <br /> S 1 S 5 I 1 ovJe,r rye S s Scy' )IPO -7 I <br /> IIII�FACILITY <br /> FACILI� TY NAME - DEALER/FOREMAN/SVFERVISORi P0.r jL( t sa n <br /> STFEET AD0RE59 NEAREST CROSS STREET <br /> _ LI �{ I tJ• Carr e� L ( co <br /> (CITY J.. _ ._ _..__--.,_—.._�` COU TY <br /> Zm <br /> Via.(., <br /> --- <br /> IY.a.ILI ADDRES CZT ST <br /> 6 Z• <br /> IFHOKE W/AREA COP° TYP OF BUSINESS -- <br /> (; 01 GASOLINE STATION ( ) 02 OTHER <br /> 'N -TER OF CONTAII:EPS ,( RVRAL AREAS ONLY TOWNSHIP RANGE SECTION ---� <br /> 1II 24 HOUR EMERGENCY CONTACT PERSON <br /> i C41S: H'AME(LAS RA":E FITST) AND FH�4�F�k/A,�E_A CCCF N GHTS: N ME(LAST NAME FIRS 1 AND HONE -J,AREA COD4 <br /> 0-1 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> iV DESCRIPTIONS <br /> ,A. ( 61.TANK ( 1 Of, OTHER: CONTAINER NUMBER 2 <br /> - <br /> iB. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UF4:NOWN <br /> - _-__- <br /> ,0. CONTAINER CAPACITY: GALLONS 1 ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE [ O2 F"i200UCT._ <br /> I_-____-___.--__ __ <br /> F. DOES THE CONTAINER TORE MOTOR VEHICLE FUEL' OR WASTE OIL T yi-YES f ) 02 NO F YES CHECK APPROPRIATE BOY.(ES): <br /> ( ) 01 UNLEADED 02 R `R ( ) 03 PPE11IUM 1 ) 04 E ( 1 05 WASTE OIL ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> IA. THICKNESS OF PRIMARY CONTAINMENT: Z�fR+ l ) GAUGE I>( INCHES ( 1 CM f ) UNKNOWN <br /> i _- <br /> ;E. l ) 01 VAULTED JLOCATEU IN AIV UNDERGROUND VAULT) 4f ",;N-VAULTED f ) 03 UNKNOWN <br /> IC. t ) 01 DO--'[LE WALLED l NSLE WALLED ( 103 LINED 1 <br /> ID, Q-tk•9r A-RSCIf STEEL ( ) 02 STAINLESS STEEL t ) 03 PIBERGLASS f 104 POLYVINYL CHLORIDE ( ) 05 CONCR;IF. <br /> ( 'T CS A.L:':'SNUH ( ) 07 STILL CLAY t 1 03 BRONZE l ) 09 COMPOSITE l ) 10 NON-METALLIC <br /> ( ) <br /> 32 Uti.KOIL( I ) 13 OTIIEC: <br /> HSC04-070105 R ----PAGE 1 <br /> I <br /> t <br /> 4 <br />