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• • STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT l ) 07 TANK CLOSED ( ) 09 DE TE FROM FILE (NO FEE) <br /> l ) 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT f ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAA>(COP.PORATION.INDI D OR PUBLIC AGENCYI PUBLIC ENCY ONLY <br /> O ��� ( 1 0 D 1 ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CI Y STATE ZIP <br /> 1 ! <br /> II FACILITY <br /> FACILITY N ( DEALER/FOPEMEN UPERVISOR <br /> UVA <br /> STREET FDC' SS NEA P,ES.,T CROSS STREET"22 F&okmE kN <br /> CITY COU(/•t'///� ZIP <br /> / /7 <br />(MAILING POOPSS STATE ZIP <br />"PHONE Wi APEA CODE TYPE OF <br /> ( ) USINES OTHERz 01 GASOLI STATION Y' <br /> / <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP NGE SECTSON <br /> III 24 HOUR EMERGENCY CONTACT XRSON <br /> DAYS: NAM,Ef LAST NAME FIRST) AND PHONE W/AR A CODE NIGHTS: NAME(LAST NAMEFI T) AND PHONE W/AREA CODE <br /> IZ - _CO -IP?G <br /> COMPLETE THE FOL WING ON A SEPARATE FORM FOR EACH CO INER <br /> IV DESCRIPTION <br /> A. 1.) 01 TANK f ) 02 OTHER: CONTAINER NUMBER .1 <br /> B. MANUFACTURER (IF APPRO IATE): EAR MFG' C. YEAR INSTALLED f 1 UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE ^ 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? L%�1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ) 04 DIESEL ( ) 05 WASTE OIL ( J 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: Y y f ) GAUGE ;)O INCHES ( ) CM yam) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> if <br /> C. ( ) 01 DOUBLE WALLED ( 7 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL I ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ) 06 ALUMINUM ( ) 07 STEEL CLAD l ] 08 BRONZE 1 l 09 COMPOSITE ( ) 30 NON-METALLIC <br /> C 1 12 UNKNOWN ( ) 13 OTHER: <br /> ISC04-070185 PAGE 1 <br />