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Permit APPlication <br /> Xol New Permit Pros Installed before July 1, 1984 , •o^„ <br /> ❑oz Provisional Permit ❑04 Installed after July 1, 1984 ❑ os Renewed Permit ❑ or Amended Permit <br /> I Owner <br /> Name cwporahon Indmdoal or Puhho Agencyl <br /> r <br /> Street Address Q <br /> /// I Dn Stale nP <br /> / <br /> ar, lCs►-t,d,a 144 78 <br /> II Facility <br /> Fawllly Name Dealer/Forman/Supervisor <br /> Man feC'u h C�. SoG Fcr,ru <br /> Sheet Address <br /> Z^L q rvearest Goss Sven <br /> IF Mie lema wf <br /> city County ZIP <br /> Mailing Adwess City Slate ZIP <br /> o . 801- 10615 Masi f�cA G!l 9$33G <br /> Phone w/area cede Type of Busmess - `_/ <br /> ZQ f' Z 3 216($ ❑ of Gasoline Station 002 Other:wl4v"dt. <br /> NO"'Ili OF CONU,INERS TOWnSnip Re e <br /> ♦T TN19 FAC IL LTy Rural Areas BPCNen <br /> Only: <br /> III 24 Hour Emergency Contact Person <br /> Days.Name real name hrsh and Phone w/area code Nights Name peal name hrsl)and Phone w:arca code <br /> Fa><4� 806 (2.09 ) <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV Description <br /> Lonbiner NurNaar Or fnne.5 no number assign oil <br /> A. Rf oI Tank ❑oz Other. � <br /> B. Manufacturer(if appropriate):—UIt�I]nt a rt 41 <br /> Year of Mfo.: C. Year Installed: 000 ❑ Unknown <br /> fs , <br /> D. Container Capacity: 160 gallons ❑ UnknownE. Does the Container Store (Check One): ❑or Waste A02 Product ' <br /> F. Does the Container Store Motor Vehicle Fuel or Waste Oil? got Yes ❑oz No If Yes, Check appropriate box(es): <br /> ❑of Unleaded Koz Regular ❑o3 Premium ❑oC Diesel ❑o5 Waste Oil ❑m Other (List): <br /> If you answered yes; do not complete Part VIII. <br /> V Container Construction <br /> A. Thickness of Primary Containment: ❑ Gauge ❑ Inches ❑ cm arUnknown <br /> B. ❑of Vaulted (Located in an underground Vault.) ❑oz Non-vaulted @A3 Unknown <br /> C. ❑o, Double Walled X62 Singl <br /> ,lined <br /> aIle ined A <br /> /d <br /> D. ❑of Carbon Sleel 0 0 Stainless Steel ❑os Fiberglass ❑or Polyvinyl Chloride ❑o5 Concrete ❑oa Aluminum <br /> ❑or Steel Clad ❑OB Bronze ❑og Composite ❑to Non-metallic ❑ ,I Earthen Walls <br /> K-1= Unknown 0 13 Ot ec <br />