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: • STATE Id NUMBER <br /> ---- APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (,(l 01 NEW PERMIT f 1 QS RENEWED PERMIT ! 1 07 TANK CLOSED ( 1 01 BELETE• FROM FILE IND FEET <br /> r -1-02 COf10ITIONAL PERMIT I 1 -06 AMENDED PERMIT 1 1 OC MINOR CHANGE 1NO 'SURCHARGE) <br /> [ <br /> OWNER <br /> NAr.fiCOPPORATION+INDIVIDUAL OP FGSLIC AOENCYI _ PUBLIC AGENCY ONLY <br /> -�_ +�/9/� / pi�"%1 f ! 01 FED 1 1 02 STATE ( .1 03 LOCAL <br /> STP[!T ACryPESS CITY <br /> r STATE <br /> 2I <br /> II FACILITY <br /> FACILITY NArE DEALER/F P/EMENloS4PEA/V�ISOP / 5^f <br /> STREET F00'ESS NEAPEST CPOSS STPEET <br /> 4-12 <br /> CITY <br /> (� <br /> 71'4 e; <br /> COUNTY <br /> Z I P <br /> MAIL[NO AODPEfS CITY L'Y STAT ZSP � <br /> PHONE W•A`EA CODE t� TYPE OF BUSINESS <br /> I O1 GASOLINE STATION 1 02 OT?IER <br /> NUI'OEP CP CONTAINEDS PUPAL APEAS ONLY : TOWNSHIP PAN6E _CT ION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: HAMC(LAST NAME FIPS 1 AND PHONE W/APEA CODE / NIONTS: HAMESLAST NAME FIRST$ AND PHONE W/APEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. <br /> �IX 1 01 TAIIK 1 1 02 OTHER: CONTAINER NLMER <br /> B�MAI{IIFACTURER 1 IF APPROPRIATE(: YEAR MFG: C. YEAR INSTALLED [ 1 UNKNOWN <br /> D. CONTAIIIER CAPACITY: <br /> - �S GALLOP{5 1 1 UNKfK]kfl E. DOES THE CONTAINER STDRE: 1 1 01 WASTE 1 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? f 1 01 TES 1 1 02 NO IF YES CHECK APPROPRIATE PDXiESI: <br /> 1 1_01 UNLEADED 1 1 02 REGULAR 1 1 03 PREMIUM 1 1 04 DIESEL 1 1 05 WASTE OIL N.06 O1HER/q�� <br /> v CONTAINER CONSTRUCTION <br /> A. TH[CY.fIESS OF PP.THARY CONT41Nf1ENT: I I GAUGE f I IfICHES t I CM 1 M UNKNOw?{ <br /> B.-f r 01 VAULTED ( LOCATED III Afl UNf)ERGROUr{O VAULT 1 1 02 NON-VAULTED f 1 03 LR{KNOWN <br /> JC. t 101 OOUBLE WILLED Al 02 SI14GLE WALLED 1 1 03 LINED <br /> 0. {Xi 01 CARBON STEEL 1 102 STAINLESS STEEL 1 1 03 FI6ERGLASS f 1 04 POLYVINYL CHLORIDE i 105 CONCRETE <br /> 1 OF ALUKINUM 1 1 07 STEEL CLAD 1 1 06 BROIiZE f 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 04KNOW11 L 1 13 OTHER: <br /> PAGE 1 <br /> Olt <br /> i <br />