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• » STATE TD NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> - --••"' �-- `-- � � ( 1 09'DELETE FROM FILE (NO FEEL <br /> Ful <br /> I CONDITIONAL PERMIT 1 06 AMENDED PERMIT NEW PERMIT { 1 05 RENEWED PERMIT { 1 07 TANK CLOSED <br /> 1 1 0� MINOR CHANGE lN0 SURCHARGEi <br /> I OWNER - <br /> _ --• - ----- -----. � _--- ------------- PUBLIC AGENCY ONLY <br /> H.r.!lCOooOpaTION,INCIVIOUxI Op FU C ADENCYI — ( 1 01 FED 1 1 02 STATE { 1 03 LOCAL <br /> CITY STATE ZIPff�� <br /> ST-!I AC'7pESS <br /> II FACILITY <br /> rAGIII NAR _ 1 DEALER/F EMEN/SVPERVISOP -- <br /> y� I _ < [-)f <br /> STFEE RCC'ESS NEAPEST CIOS5 S <br /> _—� _ � — -- - ZIP�y <br /> c.Tr cauNY� s� G <br /> - STATE ZI <br /> nAItI ADOPESSCITL <br /> ] riL1�e <br /> Q_ 11 r <br /> vNON! W,Acek CODE T►'PE of 6USINESS <br /> PPVVAL <br /> 01 GASOLINE STATION i 02 OTHERNUreEo Cf CONTAINEPS APE4S OMiY TOWNSNSP <br /> PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY NAME! AST NAME FIPSTM AND PHW M/APEA COOE tJIG TS: NAriE! AST NAM rIPST) AND PKON€ W/APEA COOS _ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IW DESCRIPTION <br /> A. t 1 01 TA}iK ( 1 02 OTHER -- -_--� --- ONTAINER NUMBER _— ,_- <br /> _ <br /> ACTUPER 1IF APPROPRIATE I' YEAR MFG: C. TEAR INSTALLED 7 { —} UNKNOWN <br /> 13. MtPI FU <br /> D. CONTAIt1ER CAPACITY. �L) bVC` GALLONS t 1 UNKNOWfT E. QOES THE CONTAINER STORE { 1 01 WASTESXI OZ PRODUCT <br /> F- DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 1-I 1 01 YES ( 1 02 NO IF YES CHECK APFROPRIATE BOX( <br /> 1 101 UTILEADED ( 1 02 REGULAR l 1 03 PREMIUM { 04 DIESEL i 1 05 WASTE OIL ! 1 0b OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TPTCI HESS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 I INCHES { t CM 1 1 UNKNOWN <br /> O1 VAULTEII (LOCATED IN AN UIIDERGROUNO VAULT I 1 X,.02 NON-VAULTED t 1 03 t1NKNOWN <br /> IC. t 101 DOUBLE N1LLE0 1` 02 SINGLE WALLED ! 1 QI LINED <br /> I0. 1 01 CAF;6OH STEEL 1 1 02 STAINLESS STEEL 1 1 03 FICERGLASS f 1 04 POLYVINTL CHLORIDE 1 1 05 CONCRETE <br /> t 1 06 ALUMINUM 1 1 07 STEEL CLAD t 1 06 BROtIZE 11 OV COMPOSITE 1 I 10 NON-METALLIC <br /> l 1 12 UIIKNOKII ( I 13 OTHER - <br /> - - PAGE <br />