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STATE ID NUMBER <br /> APPLICATION F04OPERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> l 1 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( 1 0.7 TANK CLOSED <br /> 1 _1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT f ) 08 MINOR CHANGE (NO SURCHARGE)) 09 DELETE FROM FILE (NO FEE) <br /> I OWNER <br /> NAMEICOPPOPATION.INCIVIDU4L OR PUB IC AGENCY) -- <br /> L�e, 1 + PUBLIC AGENCY ONLY <br /> dMC � 1 1 Ol FED 1 1 02 STATE f ) 03 LOCAL <br /> STREET A"RESS —' _ <br /> CITY S ATE IPP <br /> II FACILITY <br /> FACILITY Nq�,E <br /> DEALER/FOPEMENISUo VISOR ,� C <br /> ,STREET ADC'ESS NEAP T C O S FEET <br /> __1T� __S1_L_�I�1__L <br /> CITY 11 � <br /> __'F r COUNTY n �YVa ZIP <br /> MAILING ADDRESS ,sQ v '1--"— �� <br /> ---�� (�L ' 1 `h �� O CITY STATE ZI <br /> �'l Z <br /> b <br /> PHO 'E W�•P a• CODE <br /> / TYPE CF BUSINESS <br /> 3 - 01 GASOLINE STATION 1 02 OTHER <br /> NUMBEF CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP <br /> PANGS SCCTZON <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME) L4ST ME FIRST) ANP PHONE W/APER CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE WIAPEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 1 01 TANK f 1 02 OTHER: <br /> —�---- __—__ _- ----- ------- CONTAINER NUMBER <br /> B. MANUFACTURER MANUFACTURER (IF APPROPRIATE): YEAR MFG; C. YEAR INSTALLED Il 2�( UNKNOWN <br /> D. CONTAINER CAPACITY: to 000 GALLONS (=UINKNOWNSTHE CONTAINER STORE: l 1 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE R VEHICLE FUEL OR WASTE OIL ? I 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BO%IESI; <br /> i 01 UNLEADED ( ) 02 REGULAR l 1 03 PREMIUM (_) 04 DIESEL 1 1 05 ASTE OIL 1 1 06 OTHER <br /> CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE Y)Q INCHES f 1 CM I l UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f402 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE WILLED 02 SINGLE WALLED I 1 03 LINED <br /> D. I 1 01 CARBON STEEL I 1 02 STAINLESS STEEL <br /> 06 ALUMINUM 1 03 FIBERGLI 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> I ( 1 ( 1 07 STEEL CLAD ( 1 A 55 08 ROIIZE f ) 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN l 1 13 OTHER: <br /> PAGE <br />