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. � u <br /> STATE IU NU"El <br /> APPLICATION FOR PERMIT TO OHE RATE UNDERGROUND STORAGE TANK <br /> r l J <br /> 01 Nom) PFRi:IT 1 1 05 REYEWEU FLP,MIT ( ) 07 TATO( CLOSED t ) 09 DELE7: FPDM FILE (NO FEE) <br /> /� CLi:917I U;JAL PERMIT f ) 06 AME:-DED PERMIT (-) 00 MINOR CHANGE IMO SURCHARGE) <br /> I OONEP, <br /> �naMElcpRPo:l e.acr..zN VlDLvht oR PUBLIC AGEIKY) PUBLIC fSENCf ONLY— — <br /> e- r Qtl .�1/-["_' AAA-C(�S. ( ) 01 FED t ) 02 STATE ( ) 03 LOCAL <br /> �STPE ET ADDRESS Y STATE 2IP <br /> 0 0 <br /> 1I FACILITY <br /> FACILITY IJAME DEA R/FOREMAN/CUPERVIS <br /> (STREET, hD DPq„I bi L r�P/� NE hPEST C r55 STREET <br /> LI7f'/Cl <br /> IC-TY - COUNTY 2IQ1 5 <br /> 'HSIL ADORE CIT STATE II <br /> iFHD): W/AREA CODpE TYP OF BUSINESS -- <br /> A ) ( q3^ 6-1-2 LINE STATION 1 ) 02 OTHER <br /> it"`DE O DCNTAINEPS RURAL AREAS ONLY TOWNSHIP RANGE SECTION —� <br /> JIT 241 FOUR EMERGENCY CONTACT PERSON <br /> ;CAiS: NA.M°(LAST NAME &IRST) ANC HO':E AREw,COCE NIGHTS' NAMEft ST NanE FIRST( AND PHONE W:AREA CCD`. l <br /> s ��_I_ �a�� 4aa-Ik 12 f: z��Q� ral e�lk4v, (S60 ) 4 -1Y51J <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> TANK. ( ) 04 OTHER: - CONTAINER NUMBER l <br /> 5. MA\41FALTURER (TF APPROPRIATE I: YEAR MFG: C. YEAR I14STALLED/ C) l I Ut3:NOWN <br /> +�--- <br /> 'G, CONTAINER CAPACITY! GALLONS 1 ) UWNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ) 02 PRODUCT - <br /> F. DOES THE CONIAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (t-01—YES 1 ) 02 NO IF YES CHECK APOPRI TE BOYN ES): <br /> ( 1 <br /> 01 UNLEADED f ) 02 REGULAR ) 03 PR MILM 1 1 04 DfnEE05 WASTE OIL t,&06 OTHER <br /> V CONTAINER CONSTRUCTION ' <br /> — I <br /> IA, THICKNESS OF PRIMARY CORTAINTtENT: OA 24,) f ) GAUGE�j I1ICHES ( ) CM ( ) UNKNOWN ! <br /> F. l ) O1 VAULTEO_[lOCA7EU IN AN UNDERGROUND VAULT( (V-02 IJJN3-VAUL7ED f ) 03 UNKNOWN <br /> 7 <br /> IC. i ) 01 DOUOLE WALLED -_'OLE WALLED f ) 03 LINED i <br /> D. ( CARBCN STEEL ( ) 02 STAINLESS STEEL f ) 03 FIBERGLASS ( ) 04 FO LY\QNYL CHLORIDE ( ) OS CO:U:RCIE j <br /> 1 ) CS .":INUH l 1 07 5;'r.Cl. CLAr t 1 OG BRONZE l ) 09 COMPOSITE ( 1 10 NON-METALIIC II <br /> 1 ) 12 11KdR0;F.J ( ) 13 OTIIEfE—_.____—__..._-__ <br /> FSC04-070185 PAGE 1 <br />