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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (ILL 01 NEW PERMIT ( ) 05 RENEWED PERMIT 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT (f) 0 NGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CO PORAT ON.INDIVIDUAL OR PUBLI�_AGENCY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> STREET ADORES CITY ST 22P <br /> ,55 ps�os <br /> II FACILITY <br /> FACIL17y NAMED DEALE FOREMEN UPERVISOR <br /> STREET FDCPESS NEAREST CROSS STREET <br /> (1 <br /> C IT7Q COUNTY ZIP <br /> MAILING P�OPESS CITY O S 11 (QZIP <br /> bua PHONE Wi AREA CODE TYPE OF BUSINESS C <br /> - ( ) 01 GASOLINE STATION 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DA AM,EES NA��IP.ST1 AND�H ONE W/A%EA CODE NIGHTS: 7 <br /> NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> mstr <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( ) 01 TANK f 7 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG:E[ C. YEAR INSTALLED /(?7 UNKNOWN <br /> D. CONTAINER CAPACITY: l0 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE Co 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES ( l 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ) 04 DIE EL l 1 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM q�). UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 102 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> `_ ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />