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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> I O1 NEW PERMIT ( 1 05 RENEWED PERMIT I 1 07 TANK CLOSED 1 1 09 DELETC' FROM FILE (NO FEE) <br /> 102 CONOITIONAL PERMIT f 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAP.E(COPPORATION,INDIVTDUAL 09 FUSLIC AGENCY) C4 L'( Z—,' PUBLIC AGENCY ONLY <br /> S'' "` I'D f✓�I 1`1 F kiM )� f 1 01 FED r 1 02 STATE ( 1 03 LOCAL <br /> STAEE7 ACRES S e ITY,F� � STX1E tP _ <br /> 247 <br /> II FACILITY / # <br /> FACILITY NAME G41!' DEALER/FA REMEN/SVPERVISOV — <br /> STREET ACCESS Pry <br /> NEAaE5T CROSS STREET <br /> CITY / /- COUNTY V V1 4fw ZIPi7 �/V <br /> MAILING ADDRESS - CITY STA E ZIP <br /> 477 PA, <br /> PM h'. W'AVEA CODE . TYPE CF DUSINESS <br /> G �j111PAt 1 ) O1 GASOLINE STATION i 1 02 OTHER <br /> NUMpEt ['f CONTAINERS AREAS ONLY TOWNSHIP RANGE SCCTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME(LAST NAME fIRST1 ND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> a A. (>() Ol TA)1K ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEI= YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> 0. CONTAINER CA GALLONS ( I UNKNOW)( E. DOES THE CONTAINER STORE: f 1 01 WASTE ( 02 PROOUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES I 1 02 NO IF YES CHECK APPROPRIATE BOX{ESI: <br /> I 1 01 U.ILEADE4 ( 1 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL r 1 05 WASTE OIL 06 OTHER <br /> rV CONTAINER CONSTRUCTION <br /> IA. THICKNESS OF PRIMARY CONTAINMENT: [ 1 GAUGE ( I INCHES i I CM 1 UNKNOWN <br /> IB, I 1 01 VAULTED ( LOCATED IN AN UNDERGROUNO VAULT) l 1 02 NON—VAULTED f 1 03 UNKNOWN <br /> IC.�4 1 01 DOUBLE WiLLEOSINGLE MALLEO I 1 03 LINED <br /> D. I 1 01 CARBON STEEL f 1 02 STAINLESS STEEL f 1 03 FIBERGLASS C i 04 POLYVINYL CHLORIDE { 1 05 CONCRETE <br /> ( ) OF ALUMINUM ( 107 STEEL CLAD f 1 08 BR011ZE I 1 09 COMPOSITE ( 1 10 NON—METALLIC <br /> f I 12 0IKNOWII ( 1 13 OTHER: <br /> H5G185 <br /> PAGE 1 <br />