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• �f. i • STATE ID UMBER 119 <br />! APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 <br /> 1-0-1 NEN PERHIT 1 1 OS RENEWED PERHIT � 07 TAH)( CLOSED <br /> 1 1 09 DELETt FROM FILE IND FEET <br /> I 1 02 COt10ITIONAL PERMIT ( 1 06 AMENDED PERMIT 1 1 06 MINOR CHANGE IND SURCHARGE) <br /> I OWNER _ <br /> HAY.EtCOPPORATxON.IND IVIDUAI OR PUBLIC AGENCY) :::J�PUBL:IC1 AGENCY 1 LY <br /> r 1 fE0 1 1 02 STATE l 1 OS LOCAL <br /> STRCCT AO'1RESS / TITY STAT) <br /> II FACILITY <br /> FACILITY NAME Of&U R/fOPCM[NYSVPCIVSSOP <br /> A4 <br /> STRCCT &ODIC$& NCAPEST CROSS STI'll <br /> _ -103 3 5, Sc.)t43 sT — <br /> COVNTY II. <br /> C:TY <br /> CITr5\1NQ STATE ^ xxI / <br /> MAILING ADOP[SS ^ <br /> P NO HC M AR!• GOGASOLINE TY•{ Of eV3INC <br /> SS <br /> � WE -- — <br /> 1 1 O1 STATION 1 1 02 OTHER <br /> PVP <br /> )NMeCP CP CONTAINERS AI APC AS ONIY TOWNSHIP PAM OC SECTION <br /> II1 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NA Y.CtIAST NAME 12!.1171 AND PHONE N/APIA CODE NIGHTS: NAMCILAST NAME FIRST) &NO PHONE WIAREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION �1 -- ---- <br /> A. 1 1 01 TAtK 1 1 02 OTHER: CONTAINER NUMBER <br /> UNKNOWN <br /> e. MANUFACTURER IIF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLED — — (v, <br /> 0. CONTAINER CAPACIT �Q GALLONS 1 1 INKN�EDOESHE CONTAINER STORE: 1 1 01 WASTE 1 ) 02 PRODUCT —_— <br /> F DOES THE CONTAINER STORE ROTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 TES 1 102 NO F YES CHECK APPROPRIATE BO%IES I: <br /> 1 1 01 U1gEAUED ( 1 02 REGULAR 1 ) 03 PREMIUM 1 1 04 DIESEL 1 1 05 WASTE OIL 1 06 OTHER <br /> V CONTAINER CONSTRUCTION -- - <br /> I(I`A. THICPtIFSS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 1 INCHES 1 1 CM 11 UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN U110ERGROLP10 VAULTI_ 1 1 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE W%LLEO 1 1 02 SINGLE WALLED 1 1 03 LI14E0 <br /> D. IN O1 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 F16ERGLASS l 1 04 POLYVINYL CHLORIDE t 1 05 CONCRETE <br /> ' I 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 08 BROtIZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 L114KNOWIl l 1 13 OTHER: _ ---- - <br /> PAGE 1 <br /> HSC04-070185 <br />