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RS <br /> n JZjyj �1� • STATE IO NUMBER <br /> APPLICATION OR PERMIT TO OPERATE UNDERGROUND STORAGE TANK_- <br /> IS(I 01 NEW PERMIT ( 1 05 RENEWED PERMIT 1 ) 07 TANK CLOSED 1 1 09-DELETE FROM FILE (NO FEE) <br /> 1 02 C0110ITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE IND SURCHARGE .- - <br /> I OWNER ------ -- ---- --- ---- - - - <br /> N.M!(COPPORATIO>.INCIVIOURL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> �> ( 1 01 FEB 1 1 02 STATE 1 1 03 LOCAL <br /> sieFET AC'1PE'S CITY STATE IIF <br /> II FACILITY _ _ -- <br /> FACI ITf NAME 0 e Aq ER/F OR E ME N SUP E P V I SOP <br /> STREET RCC°ESS J' NEAREST CROSS STREET <br /> tao <br /> CITY t— COUNTY IIF <br /> -- ,fir <br /> ICI 4. Sc1(,TE I� y <br /> MAILING A00PE SS /( �,l <br /> 11yM„x._�1 l 7 �---_ <br /> PHONE W•-ASF• CODE TYPE OF BVSINESS _ — <br /> 'T 2/fl 1 1 01 GASOLINE STATION 1 02 OTHER <br /> NUf DER CF CONTAINERS RURAL AREAS OHIY TOWNSHIP _-- RANGE _ SECTION <br /> III 26 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAr,F1 UST NAM! FIP I NO PHONE N/ARBA C00! ONTS: Ny'EILAST NAME FIRSTI AND PHONE WIAPEA COOF <br /> Lt>9a� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> I V DESCRIPTION <br /> _ - –___ -------- <br /> A. 1 O1 TANK ( 1 02 OTHER: CONTAINER NUMBER _ -- <br /> B. MANUFACTURER fIF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLE0t(6 1 UNKNOWN <br /> 1 <br /> 0 CONTAINER CAPACITY: (b DOV GALLONS l I UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE 1X) 02 PRODUCT -- <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? &J, Ol YES ( 1 02 NO IF YES CHECK APPROPRIATE BOK(ESI: <br /> 1 1 <br /> 01 UIILEADED I ) 02 REGULAR ( 1 03 PREMIUM 1p4 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> fq, THICI.NESS OF PP.IMARY CONTAINMENT 1 1 GAUGE ( 1 INCHES 1 1 CM V. 1 UNKNOWN <br /> B. I 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT IJC.L 02 NON-VAULTED 1 1 03 UNKNOWN <br /> iC. I 1 01 DOUBLE WILLED 1 102 SINGLE WALLED 1 1 03 LINFO <br /> i0. ( 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL I 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> �Q1 1 OP ALUMINUM 1 1 07 STEEL CLAD 1 1 OB BR0112E 1 1 09 COMPOSITE I 1 30 NON-METALLIC <br /> 111 12 UNKNOWN ( 113 OTHER: <br /> PAGE 1 <br /> 11D A4-07^1R5 <br />