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,two •.ld' <br /> STATE ID HUM3EP <br /> APPLICA !ION FOR PFRHIT TO OPERATE UNDERGRDUHI) STORAGE TANK <br /> 03NO <br /> —01 NFA PFRM _ 1 ) OS RE 1EWED P =M[T ( ) 07 C.LOSED — f ) 09 DELE. LH FILE U" EEE I-I <br /> I 100012 CV 1J iI7tJA1, il[RMII ! I Ob klii`� FG <br /> d�) PMT I ( 1 03Ml:NDR C11AlIGF. fNG SURCHARGE) <br /> I OONFR <br /> NAME(CORiORAT ION, NDIVIDUAL OR R�ULILIF AGENCtI PUBLIC ABEHCt ONLY <br /> -- - <br /> -�e7lQ/_2�Lnn--- .— �u.-fJan. _ ( ) oI !ED ( ) oz STAT ( I 03 LOCAL <br /> !S'REET AOOPESS CITY STATE ZI ' <br /> 11 FACILITY <br /> (FACILITY NAME DEALER/FO MLN/'UPERV <br /> MPEET AODF ESS NEAREST CROSS ST ELT <br /> ;CITY COUNTY ZTP <br /> F.aILINu ACDRE SA . O v.`^�• L_!'—; / _—. STAT_ <br /> 'PRUNE W/AREA CCC-- !TYPE OF 6USINESS <br /> 0 )- 01 GASOLINE STATION ( ) 02 OTHER � <br /> It "IEP OF CCR*A71—rF--�—� -�RVRAL AREAS Un1iY TOWNSHIV <br /> JIT 24 HOJR EM_RGENCY CUNTACT PERSON <br /> ICA15: M !LAST Ill.^.E Ff'-e—) p' /i K,r. CC' 191 is; N`ME lA. ( NAME FIRST) AND F'PONE W,AREA CODE <br /> �vr7� Lz161I_ � �( C.� Q -4?174s�_� I <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> iV DESCRIPTION <br /> 16 TANK ( 1 04 OTHER_— --- CONTAINER NUMBER -- i <br /> 18. MANUFACTURER (IF APPRUP^n LATE): YEAR MFG: C. YEAR INSTALLED / (��Ut+}:NOW1J ! <br /> I <br /> i <br /> !0. CONTAINER CA?ACITY: GALLONS ( ) UNKNOWN E. DOES THE CUITAINER STORE: ( ) 01. WASTE D�) yli.-•PRDDOCI' � <br /> fF, DOES THE CONTAINER STORE MOTOR V'= LE FUEL OR WASTL: OII_ 7 1*( -01 YES 1 ) 02 NO IF YES CHECK APVROPRIA F. 130Y(ES1: I' <br /> ( 1 <br /> 01 UNLEADED l ) 02 REGULAR ) 03 PP'HIUM 1 1 04 11IE5El 'l ) OS WASTE OIL 4g$p00 OTHER <br /> V CONTAINER CUNSTRUCION <br /> A. THICKNESS OF PRIMARY t:ONTATI.rlENT: O ( ) GAUGE TIES ! ) CM ( I UIJKNOIJN <br /> !E, l ) 01 VAULTED (LOCATED IN AN UNUERGROUNO.VAULT( ( 02 14N-VAULTED ( ) 03 UNKNOWN <br /> IC. l ! 01 OOUOLE NALLED fqk0- SINGLE WALLED 1 ) 03 LINED <br /> I0. l�k-tARSC•t STF,EL ) 02 STAINLEFS tLTEEI. l 1 03 1'IBE:'GLASS--( ) 04 POLYVINYL CHLORIDE ( ) 05 CO'U:RET'E I <br /> ( ) OS ALL-NINU11 ( ) 07 ST5 EL CLAD I 1 00 BRONZE l ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> I 1 )2 UNXC ,^1114 I 1 13 OTHER: ' <br /> F5C04-070185 PAGE I <br />