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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK l <br /> N1 01 NEW PERMIT -i 1 05 RENEWED PERMIT I M 07 TANK CLOSED I 1 09'OELETE FROM FILE (NO FEE) <br /> 1 f ) 02 CONDITIONAL PERMIT I 1 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (N0 SURCHARGE) +I <br /> I OWNER <br /> N.MEgCOPPOPA7ION,INCIVI0U4L OR PUBLIC AQENCY1 PUBLIC AGENCY ONLY <br /> ell FL Of SN0cX17ty- <br /> 01 FED I 9 02 STATE N1 03 LOCAL <br /> STPE!T ACnR*SS -- CITY STATE— ZIPr <br /> �� NAV ��V'E. ---•.---�3 T aC.KCds — C.f3 �1 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPEPVISOP <br /> STfEET ADC'ESS NEAPEST CROSS STPEET <br /> --- 9500 NoNly E --- �_ T 1�-►.1t 1�3.w�S Dv� — <br /> C:TY COUNTYZIP <br /> wA l ypl l <br /> MAILING ADDPESS - CITY STATE ZIP <br /> -- U S�+aC. '1Z (`'lbs <br /> P>tONE W'AcE ^ CO � TYPE OF BUSINESS <br /> AR <br /> I 1 01 GASOLINE STATION Ir I 42 OTHER <br /> NUt'BER CF CONTAINERS ` PUPAL APEAS ONLY : TOWNShIP ,— RANGE SECTION ----^ <br /> III 2/, HOUR EMERGENCY CONTACT PERSON <br /> CDON <br /> AYS: NAr,ErLAST �NAtMrE FIRST) AND PHONE W/ARE��QE � NI�TS`� AMEI LAST�NAME F�ND-PN��WyA�A��pE <br /> 11,)G <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> I v DESCRIPTIONA. f,< 01 TAIIK ( 1 02 OTHER: ---- ----- - ---_.- ---��__I COtITAINER t+R1i1Bf R ' "���'L'�•� -- �_ <br /> B. MANUFACTURER (IF APPROPRIATE): ---_--- f- --- -- - YEAR MFG—to { FAR INSTALLED M4 I 1 UNKNOWN <br /> D. CONTAINER CAPACITY: Sav GALLONS i I UNKNOWN f. ODES THE CONTAINER STORE I 01 WASTE f 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 7 ( 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOXIES)' <br /> 1 1 01 UNLEADED 4 1 02 REGULAR ( ) 03 PREMIUM t 1 04 DIESEL KI 05 WASTE OIL I ] 06 0111ER <br /> V CONTAINER CONSTRUCTION <br /> A. TP10NESS OF PP.IMARY CONTAINMENT: .X I 1 GAUGE (>o INCHES [ k CM I ) UNKNOWN <br /> B. ( ) 01 VAULTED t LOCATED Itt AN UHf)ERGPOUft0 VAULT I XI) 02 NON-VAULTED 1 f 03 UNKNOWN <br /> �C. 1 1 01 DOUfi(E W1LLE0 <br /> o< 02 SIt)GLE WALLED 1 ) 03 LINED 1 <br /> D. 11,01 CARBON STEEL 1 1 02 STAINLESS STEEL E 1 03 FIEERGLA55 f 1 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD I 1 08 BRONZE f 1 04 COMPOSITE I 1 10 NON-METALLIC <br /> ( 1 12 L4tKt4OWt4 ( 1 13 OTHER: <br /> N��04-01^1fi5 PAGE 1 <br />