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:f • STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f <br /> �I 01 NEW PERMIT I 1 05 RENEWED PERMIT I 1 07 TAM( CLOSED <br /> 1 ( 1 00 OELlTC FROM FILE (NO FEE) <br /> r +02 COt1OITI0NAl PERMIT` _[ 1 Ob AMENDED PERMIT i 1 00 MINOR CHANGE IND SURCHARGE) <br /> [ OWNER --- <br /> ""'"COPPORATION,INDIVIOVAI OR PUBLIC AGENCY) -- <br /> [1 ;7 p PIJetIC AGENCY ONLY <br /> -- —�'— r � r� I\T� j _ 1 1 Ol FED [ 1 02 STATE I .1 03 LOCAL <br /> ITPEex Ac�t+Es$ <br /> CITY <br /> STATE ZIP <br /> Ii FACILITY <br /> FACItITV NAME <br /> DEAL EN/FOPEMEN-ISUPERVZSop <br /> STREET ROC`�ESS9 NEAREST CROSS STPEET <br /> �G <br /> CITY �� COUNTY a �7 _� - <br /> r G�J <br /> ZIP <br /> MAR IN0 ADpPE55� CITY <br /> s7,// STAT[ - :I - r� <br /> Px01:_ W.ADEA Cove TYPE OF BUSINESS / J` `rrT/j� �' <br /> c7ry ' yo moi, 1 1 01 GASOLINE STATION 1 02 OTHER <br /> NVYB[f Of CONTAINED$ PUPAL APEAS QNLY : TOW N$N;P RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NAME fLAST NAME FIPSTI AND PHONE W/AREA CODENIpHTS: NAME(LAST NAME FIRST) ANO PHONE W�AREA COOE <br /> u 1i r/ Sty ?ter✓` - /—j <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />'S A. I 1 01 TANK 1 102 OTHER: CONTAINER NUMBER — <br /> B. MANUFACTURER (IF APPROPRIATEl' V N J YEAR MFG: C. YEAR INSTALLED f�']6 1 I UNKNOWN <br /> D. CONTAINER CAPACITYY=_5 5- GALLOtIS <br /> -7W NOWN E. DOES THE CONTAINER STORE: i 1 01 WASTE 1 1 02 PROOUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ' I 1 01 YES I 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> 1 1 01 (P+LEADCO I 1 02 REGULAR 1 103 PREMIUM { 1 04 DIESEL { 105 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKtJESS Of PPIMARY CONTAINNFNT: t I GAUGE 1 I ItICHES [ 1 CM I I UNKNOWN <br /> B. f 01 VAULTED (LOCATED IN AN UI:OERGROUPl0 VAULT) I I 02 NON-VAULTED 1 1 03 Ut4KNOWN <br /> �C. t I (11 DOUBtE WILLED f d 02 SINGLE WALLED _1 1 03 LIt1E0 '--- - --- - <br /> 0. 1 ) 01 CARBON STEEL I 1 02 STAINLESS STEEL 1 d 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE t 1 05 CONCRETE <br /> ) ON ALUMINUM I 1 07 STEEL CLAD ( 1 OE BROt1ZE 1 1 00 COMPOSITE I 1 10 NON-METALLIC <br /> I M 12 L111KNOWN l 1 13 OTHER: <br /> OISC04-0;0185 --- — _— _ - ----- - ------- - -- - - -- <br /> PAGE 1 <br /> .la+l4 • � � � _ <br />