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Permit Application <br /> _ter <br /> Pot New Permit (dos Installed before July, 1, 1984 <br /> ❑02 Provisional Permit ❑04 Installed after July 1, 1984 ❑ o3 Renewed Permit ❑ of Amended Permit <br /> I Owner <br /> Name ICorpWaaon individual or Public Agency, <br /> dtH C7rfyr MQamu' a. <br /> Street Address City Sale ZIP <br /> I'M 15 ? Nf S L deo 9 s�8 <br /> II Facility <br /> Faclldy Name <br /> Dealer/Forman/Superrsor <br /> MQ,N�ca 8-(?a,,;-7 �o M i. Bah Fc4x& <br /> Street Address _ <br /> DSK s�- <br /> Neared Cross street <br /> � � <br /> city M �� <br /> Q K County <br /> Still <br /> ZIP <br /> Willing AddrQSS cityr� S131e ZIP ZIP <br /> P. Q • 8�K I ob 3 i+%td�i�c.l.. Cf'( Q533,� <br /> [THIS <br /> one vi cod s�neaa <br /> Type of ap <br /> 20 9 823- 46r 5 ❑ of Gasoline Station ❑oz Other: <br /> NU PER <br /> OF CONTAINERS Toymabip Ran <br /> n li_•Tr Rural Areas ge Section <br /> Only: <br /> III 24 Hour Emergency Contact Person <br /> Days Name,last name IRstl and Phone w/area code Nights Name hast name halt and Phone w'area code <br /> Mr. ,304 FlcXa (?671 823 -KG/S <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description <br /> COnlalner Nurrda4r oI,nere e,no number assgn or <br /> A. �m Tank ❑os Other. 3 <br /> t <br /> B. Manufacturer(if appropriate): J'lOGJO Year of Mi �-�� C. Year Installed: I?q8 ❑ Unknown <br /> D. Container Capacity: gallons ❑ Unknown E. Does the Container Store (Check One): ❑of Waste IKQ Product <br /> F. Does the Container Store Motor Vehicle Fuel or Waste Oil? 04, Yes ❑oz No If Yes, Check appropriate box(es): <br /> ❑at Unleaded ❑oz Regular ❑oa Premium Mod Diesel ❑os Waste Oil ❑os Other(List): <br /> If you answered yes; do not complete Part VIII. Y 1/L'ul Ii das� <br /> V Container Construction <br /> A. Thickness of Primary Containment: — ❑ Gauge ❑ Inches ❑ cm Unknown <br /> B. ❑of Vaulted (Located in an underground Vault.) ❑oz Non-vaulted Jew Unknown <br /> C. ❑o, Double Walled i�l 02 Si a Walled m Lined <br /> t: D. ❑It, Carbon Steel ❑oz Stainless Steel ❑o0 Fiberglass ❑o, Polyvinyl Chloride ❑os Concrete ❑os Aluminum <br /> ❑or Steel Clad ❑its Bronze ❑o,Composite ❑to Non-metallic ❑ 11 Earthen Walls <br /> �yz Unkno 0 3 Other <br />