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Permit Application <br /> F(ot New Permit W{ea Installed before July 1, 1984 ❑ o5 Renewed Permit ❑ of Amended Permit <br /> ❑ox Provisional Permit ❑04 Installed after July 1, 1984 <br /> I Owner <br /> Name 1Corporaaon Indnldual or Pubho Ageneyl <br /> G,' run 9&6&,t,%-0t4_ Ce. <br /> Street Address Cn <br /> gale ZlP <br /> ill/ / 51 fah Gc• .�, 9 578 <br /> II Facility <br /> Facady Name Dealer/Foreman/Su <br /> pemsw <br /> Man �eeo_ �3CeZs? C'o . /u/ • Box iexa <br /> Slreel More55 Nearest Goss Sbeel <br /> 1 ')L- s+ 6&i*Lf <br /> C4' Counly ZIP <br /> M e vvf ceA_ �,oi 953 3 G <br /> M&W,Address Cly Stale ZIP <br /> P. 0 o 3 M[*'�Cea Gw 1 95 -536 <br /> Phone w/area codeType or Business <br /> 2417 0/2 3 �6/$' ❑ of Gasoline Station Xoz Other: ItJa�f" .Lt-- <br /> NUMPEM OF CONTAINERSNUr�I AreasTownsnrp Range Senior <br /> AT TH15 FAclLLTr <br /> Only. <br /> III 24 Hour Emergency Contact Person <br /> Days Name Ilasl name hrsll antl Prone w/area code 1gms Name oast name hrsll and Prone w'area code <br /> ;77 �, 6 ; rZ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description <br /> C;enlalber Number(itIhcre is no number aSegn once <br /> A. 01 Tank ❑oz Other. 2 <br /> Ua.�cYuwn ¢S <br /> B. Manufacturer(if appropriate): Year of Mfa.: C. Year Installed: /9�B ❑ Unknown <br /> D. Container Capacity: to gallons ❑ Unknown E. Does the Container Store (Check One): ❑o1 Waste �Koz Product <br /> F. Does the Container Store Motor Vehicle Fuel or Waste Oil? 901 Yes ❑oz No If Yes. Check appropriate box(es): <br /> ❑o1 Unleaded ❑oz Regular ❑03 Premium Ngo Diesel ❑os Waste Oil ❑op Other (List): <br /> If you answered yes; do not complete Part VIII. <br /> V Container Construction ,,...�.�tt .� <br /> A. Thickness of Primary Containment:�4t»A'h❑ Gauge ❑ Inches ❑ cm la-Unknown <br /> B. ❑o1 Vaulted (Located in an underground Vault.) ❑oz Non-vaulted 03 Unknown <br /> C. ❑of Double Walled �Lw Sing W Ile ❑os Lined <br /> r' <br /> D. ❑o1 Carbon Steel ❑oz Stainless Steel ❑o3 Fiberglass ❑N Polyvinyl Chloride ❑os Concrete ❑w Aluminum <br /> ❑of Steel Clad ❑oa Bronze ❑m Composite ❑10 Non-metallic ❑ ,1 Earthen Walls <br /> z Unkrjown ❑1 r �Oth r: <br /> sf�� <br />