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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 <br /> 01 NEW PERMIT f 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 DELETE FROt FILE 0 FEE) <br /> 1 102 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) OQ MINOR CHANGE (NO SURCHARGE) — - <br /> 1 <br /> OWNER <br /> ----- -- ---- -- <br /> �HAY.EN POR ION.INO VIDUAL OR FU LIC AS NCYI PIIS LIC AGENCY ONLY <br /> j �� � �� \�-���,,.�� — - l I of FED 1 1 02 srAr l ) 03 LOCAL_ <br /> L----- TATE I <br /> — <br /> IP <br /> STPEET ADDRESS CI SqSS <br /> II FACILITY <br /> t DEALER/FOPEMENISUPERVISOR <br /> ITACIL Y NAME <br /> 71 F1 NfAPESF CROSS STp.EET I <br /> kSTFEEf 4C\ � <br /> !CITY COVN Y 2IP <br /> `C �!t4ILING ADDRESS CITC1 STATE ZIP 1 <br /> 5 <br /> pH ::♦C e CODE 2 TPE OF BUSINESS <br /> I 01 GASOLINE STATION 02 OTHER <br /> NUMBER CF CONTAINEPS lO t,PUPAL AREAS ONLY : TOWNSHIP --_- RANGE SECTION <br /> I'II 24 HOUR EMERGENCY CONTACT PERSON <br /> ((GAYS: NAP.EILAST NAME FIPSTI AND PHONE 141A' A CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W A EA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV /DESCRIPTION -- _ _ 2 ------ <br /> - ISA. W 01_iAt(K 1 1 02 OTHER_ _ CONTAINER NUMBER J -- <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 11 S( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: 55C) GALLONS l 1 UNKNOW�EDOES"THE�COONTAINER STORE: (�-WASTE ( ) 0 PRODUCT <br /> ��F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ?�Y}'� �A�/Y'ES'�f, 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 O1 UNLEADED l 1 02 REGULAR ( 103 PREMIUM ( 1 04 DIESEL �ryy3 BASTE OIL l 1 06 OTHER _. <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: l ) GAUGE 1 1 INCHES [ ) CM l 1 UNKNOWN <br /> B. 1 1 01 VAULTED ILOCATED IN AN UNDERGROUND VAULT) 2 NON-VAULTED 1 1 03 UNKNOWN <br /> i((C. 1 DOUBLE WILLED ( 1 02 SINGLE WALLED ( 1 03 LINED <br /> �0. 1 1 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 C NCRETE <br /> ( 1 06 ALUMINUM l 1 07 STEEL CLAD l 1 08 BRONZE 1 ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> f <br /> 1 12 UNKNOWN l 1 13 OTHER: <br /> _-- - PAGE 1 <br /> HSC04-070185 <br />