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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT I 1 05 RENEWED PERMIT K) 07 TANK CLOSED — � ) 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT I 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARU 1 <br /> I OWNER <br /> NAME COPPOPA ON,INOIV UAL OR PUBLIC AGENCY) yp <br /> LIC AGENCY ONLY <br /> --- a' 1 V�ctl�Ic . I� � <br /> 01 FED i 1 02 STATE ( 1 03 LOCAL <br /> STREET AD^PESS T` CITYSTATIS ZIP <br /> c-r 0 c- ce.(1J-ear- O r_w -e- U ct r6-- <br /> I I <br /> --II FACILITY <br /> FA ILITY NAME DEAL R/FOPEMEN�SUPERVISOP <br /> STREET ADD=ESS NEAPEST ,CROSS STPEET <br /> U <br /> CITY COUNTY ZIP <br /> MAILING AODPES � � CIT Y „ _ STATE ZIP <br /> c o ` t d(�� <br /> PHONE W'APEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION 11 02 OTHER Cly <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY : TOWNSHIP PANGS SECTION <br /> --------- ------- --- ------ - <br /> III 24 FLOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST AME FIP.S ) A D PHONE W/AREA CODE <br /> Z9 - f - X032 <br /> -' <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />.•a — - ----� — ---- _ TAINER NUMBER <br /> A. f ) 01 TANK ( ) 02 OTHER= CON — <br /> B. MANUFACTURER CIF APPROPRIATE ): YEAR MFG_ C. YEAR INSTALLED Y ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: DD O GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE' ( 1 01 WASTE (�1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE ROTOR VEHICLE FUEL OR WASTE OIL ? ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)= <br /> f 1 01 UNLEADED C ) 02 REGULAR ( ) 03 PREMIUM ) 04 DIE €L ( ) 05 WASTE OIL —1 ) 06 OTHER��__— <br /> V CONTAINER CONSTRUCTION <br /> A. THICY,PIESS OF PRIMARY CONTAINMENT: I ) GAUGE ( 1 INCHES f I CM 1 ) UNKNOWN — <br /> 01 VAULTED (LOCATED IN A1# UNDERGROUND VAULT I 02 NON—VAULTED 1 1 03 UNKNOWN <br /> IC. C— 1 O1 DOUBLE WILLED 1 02 SINGLE WALLED 1 1-03 LINED-- — v---v T— _..._— -- -------------- <br /> D. <br /> 01 CARBON STEEL C ) 02 STAINLESS STEEL ( 1 03 FIBERGLA55 ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> 1 06 ALUMINUM l 107 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE C ) 10 NON—METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> . HSC04-010185 �--- �.�-- ---- ------- �--- PAGE 1 <br />