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L:. <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 1 09 DELETE FROM FILE (NO FEE) <br /> 1 02-CONDITIONAL PERMIT 1_1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMEICOPPORATION.INCIVIDUAL OR PVBL C AGENCY) PUBLIC AGENCY ONLY <br /> ( I O1 FEB 1 1 02 STATE 1 ) 03 LOCAL- <br /> STREET ACORESS =J CIT STATE ZIP <br /> --- -ZL7 I Ny v _ yrZo <br /> II FACILITYY;. <br /> FACILITY NAME, DEALER/FOPEMENISUPERVISOP <br /> __� rt SEKVIG�S <br /> STREET ACCESS NEAPEST CROSS STREET <br /> CITY COVNTY�NrD u IN Z P <br /> I,kp MAILING ADDPESS� / CITY ✓Jf STATE ZIP Z7 <br /> PHONE WIAPEA CDOE TYPE OF BUSINESS <br /> 36 <br /> 01 GASOLINE STATION f 1 02 OTHER <br /> NUMBER CF CONTAINEPS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> kPAYS: NAY,E(LAST NAME FIPST YNO PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 1v4'ivo L '1�r-�!f/3-Y66 2— <br /> COMPLETE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. f 1 01 TANK f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLED l ) UNKNOWN <br /> -- - -- ------- --- - <br /> dl' <br /> 7�bX <br /> D. CONTAINER CAPACITY: s-000 GALLONS 1 ) 11NKN04R1 E. GOES THE CONTAINER STORE: f 1 01 WASTE J)< 02 PROD CT ( <br /> F. DOES THE CONTAINER TORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f 1 01 UNLEADED ( 1 02 REGULAR l ) 03 PREMIUM 1 1 04 DIESEL ( 1 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE f 1 INCHES f ) CM l I UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 1 02 NON-VAULTED 1 l 03 UNKNOWN <br /> IC. l 1 01 DOUBLE WILLED g7�02 SINGLE WALLED ( 1 03 LINED <br /> 0. 1 hlfYl CARBON STEEL ( 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> 06 ALUMINUM l ) 07 STEEL CLAD [ 1 08 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN l 1 13 OTHER: <br /> HSC04-00185 PAGE 1 <br />