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r <br />STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />LV,Urd4" REW PERMIT l 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( 1 09 OELETE'FROM FILE (NO FEEI <br />1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />AND PHONE <br />NAME(COPPORATION.INOIVIDUAL OR PUBLIC A NCY1 <br />NIGHTS: NAME(LAST NAME FIRST) A <br />STcEET ACORESS <br />W/APEA <br />II FACILITY <br />FACILITY NAME <br />r r_� 4 1 3 <br />ISTREET. hCC'ESS <br />(CITY <br />1 MAILING A FESS <br />1 J <br />CIT <br />PUBLIC AGENCY ONLY <br />l 1 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br />STATE ZIP <br />�V,, I F�66 -7/ <br />DEALER/FOPEMEN/SUPERVISOP <br />NEAPEST,CROSS $TPEET <br />COUNTY <br />PHONE W•AcEA CODE TYPE OF BUSINESS <br />"�(�66 5_q5LS <br />( ) 01 GASOLINE STATION ( 1 02 OTHER <br />NUrBEP CF CONTAINECS �JIJPAL AREAS ONLY TOWNSHIP DANCE <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />F <br />ZIP <br />STAN ZIP <br />SECTION <br />'AYS: NAMEILAST NAME fIPST� <br />AND PHONE <br />/APER CODE <br />NIGHTS: NAME(LAST NAME FIRST) A <br />D PHON <br />W/APEA <br />CODE <br />A -P fc r 0 r✓cc - <br />Old <br />�� <br />- -7b <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER�~"� <br />IV DESCRIPTION <br />6 A. 0 ARAB ( 1 02 OTHER: <br />CONTAINER NUMBER j <br />B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 7 0"/ ( 1 UNKNOWN <br />D. CONTAINER CAPACITY:IZ/ b�0 GALLONS ( ) LMI(NOWt1 JE. DOES THE CONTAINER STORE: ( 1 01 HASTE ) 02 PRODUCT — — <br />F 0 S THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? t&U.04-TES l 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br />( 1 0 .ILEAOEO ( 1 02 REGULAR l 1 03 PREMIUM ( 1 04 DI EL l 1 05 WASTE OIL Adg,06 OTHER - <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PRIMARY CONTAINMENT: 0.2_ <br />�qb ( ) GAUGE-iHCHES ( 1 CM 1 1 UNKNOWN <br />B. ( 1 01 VAULTED (LOCATED IN AN UH0ERGROUNO VAULT) l)02 N -VAULTED ( 1 03 UNKNOWN <br />IC. ( ) 01 DOUBLE WILLED ( )t SIt L -E -WALLED 1 1 03 LINED <br />D. 1 ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL Q 03 FI-6ERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) Ob ALUMINUM 1 ) 07 STEEL CLAD ( 1 O�rZE 1 ) 09 COMPOSITE ( 1 10 NON-METALLIC <br />( ) 12 UNKNOWN l 1 13 OTHER: <br />HSC04-070185 <br />PAGE 1 <br />