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STATE ID NUMBER <br /> _ APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> I NEW PERMIT f ) 05 RENEWED PERMIT 1 1 07 TANK CLOSED ( 109 DELETE FROM FILE (NO FEE) <br /> b2 CONDITIONAL PERMIT _-1 ) 06 AMENDED PERMIT _ ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMrrCOPPCRATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br /> STREET Ao7PESSJ _ CITY � ST TF LIPQ '�7 <br /> I I F A C I L I T Y <br /> FACILITY NA.E_ <br /> ,., /(✓ t�©11'11_--_�l L�� � 6I/l � DffALEP/FOPEMEN/SQPERVISOP/ ��.C�P�/�+-/vC/!'✓ <br /> STPEET\T"jAACDI9ESS NEAPEST CROSS STPEET <br /> ltvexlo e- <br /> CITY <br /> .—__ ,. �•. — --T- COUN7YY�N V�6'�,L/l��•o ZY. ���/,. <br /> MAILING ADDPESS <br /> - —�-- � 5�! /'�' !!! •Y i D VVI`1 T CiFY��/ f,STATE LIP <br /> k <br /> PHONE W,AGEA C4,DJ TYPE CF BUSINESS <br /> yZ f ) 01 GASOLINE STATION I I 02 OTHER <br /> NUMBER CF CONTA VEPS v PU4AL APEAS ONLY TOWNSHIP PpNGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> LAYS: NAMES LAST NAME FIPST) A1qD PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA COD <br /> U� r •- Gf Z Z n5 - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIFTION <br /> •s A. J)r) 01 TAW C ) 02 OTHER <br /> ICO)4TAI14EP NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): _— YEAR MFG: _ � C. YEAR INSTALLED t ) UNKNOWN <br /> 0. CONTAINER CAF GALLONS i ) LMKNOWN E.' ODES THE CONTAINER STORE: ( 1 01 WASTE 02 PRODUCT <br /> -— _-- --------------rllik� <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES f ) 02 NO IF YES CHECK APPROPRIATE 8 X(ES)- <br /> ( v) 01 UNLEADED ( 1 02 REGULAR f ] 03 PREMIUM ( l 04 DIESEL f ) 05 WASTE OIL Y_ 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT' ( ) GAUGE f I INCHE5 ( ) CM f I UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 1 02 NON-VAULTED f ) 03 UNKNOWN <br /> fC. ) 01 DOUBLE WILLED Plg� 02 SINGLE WALLED I ) 03 LINED <br /> D. C 1 01 CARBON STEEL f 1 02 STAINLESS STEEL t 1 03 FIEEPGLASS ( ) 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> I ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE C ) 09 COMPGSITE f ) 10 NON-METALLIC <br /> f 12 UNKNOWN f ) 13 OTHER: <br /> H�C04-0 01$5 PAGE 1 <br />