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STATE IO NUMBER <br /> APPLICATION FOR PERMIT 701 OPE TE UNDERGROUND STORAGE TANK <br /> 1 1 01 NEW PERMIT 1 1 05 RENEWED PERMIT l 07 TANK CLOSED l 1 09 DELETE FROM FILE (NO FEE) <br /> 1 ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE (NO SURCHARGE) 1 <br /> ( OWNER <br /> IHAY.EI COOPORATION.IND,I[�/IDWI�fQR F, 6 IC AGENCY) PUBLIC AGENCY ONLY <br /> �dl� :7Y ZAP= — 1 1 O1 FEO 1 1 02 STATE 1 1 03 LOCAL <br /> STP!!T AC90ES2 CITY STATE ZIP <br /> II FACILITY <br /> r------ - <br /> fA I ITY NAC, OFALEO/FOREMEN/SVP ERVISOR <br /> :TREET XCCVIESS tt GG)) NEAPEST CROSS STREET <br /> IT COUNTY ZIP <br /> 15 hN <br /> I _MAM INO ADORELS - CITY STATC ZIP <br /> -til <br /> _ MON! WIAPEA CODE TYPE Of SUSINASS 1/ <br /> GASOLINE STATION ( _f02 OTHER <br /> NIH'6C0 CF CONTAI NCS- ---- PUPAL AREAS ONLY 1 TOWNSH IAV --_- RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME,LAST NAME FIPST1 AND PHONE W/APER CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> � <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> A. V-1 Ol TANK t ) 02 OTHER: CONTAINER NUMBER AV ,)✓w 6) <br /> B. MANUFACTURER (IF APPROPRIATE)- f"P" ' YEAR MFG: C. YEAR INSTALLED IyP UNKNOWN <br /> T_– <br /> LFOO <br /> CAPACITY�s(jjj GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 Ol HASTE 1✓1 02 PRODUCTES E CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (,") Cl YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( �1'Oi UNLEADED ( 1 02 REGULAR l 1 03 PREMIUM 1 1 04 DIESEL ( 1 05 WASTE OIL 1 106 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 ) GAUGE 1 1 INCHES 1 1 CM 1x1 UNKNOWN (��1�_ <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Od 02 NON-VAULTED 1 ) 03 UNKNOWN D 1l <br /> C. 1 1 Ol DOUBLE WALLED (U,) 02 SINGLE WALLED 1 1 03 LINED JUN <br /> 0. 1 1 01 CARBON STEEL f 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD [ 1 OB BRONZE ( 1 09 COMPOSITE ( 110 NON-METALLIC ENVIROMENTAL HEALT <br /> ) 12 UtXNOWN ( 1 13 OTHER: EERM13 ISERVICLS <br /> HSC04-0:0185 PAGE I <br />