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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t <br /> C7041--N–EW PERMIT l 1 OS RENEWED PERMIT l 1 07 TANK CLOSED ( 1 09 OELETE, FROM FILE (NO FEE) <br /> 1 C0140ITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I ObINER <br /> NAME tCOP POPATION, CIVIDUAL OFUIC f�GENCYI PUBLIC AGENCY ONLY <br /> ---- f�r R NJJr Q I 01 FED 1 1 02 STATE ( ) OI LOCAL- <br /> STCECT aCORESS �ITY ST ZIP oO-7 <br /> II FACILITY <br /> FACILITY NAME DEALER/FCPEMEN/SUPEPVIS <br /> STPEET FCC'ESS HEAP T CROSS STPEET <br /> 3� t � � , c � E ( � « 7n-c <br /> CITY �At li� <br /> CO NTY ZIP <br /> I MAILING (�(7DP]ESS � CIC<Y S A ZIP <br /> �/Lo <br /> PHONE WAVE UCODE TYPE OF !lUSINESS <br /> - jqt <br /> 01 GASOLINE STATION ( 1 02 OTHER <br /> NUrpEP CF CONTAINEcS PUPAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NA E FIP$T 1 ANO PH NE W/A?EAC DE NIGH N ME( AS NAME FIRST 1-AN PHOU W/APE `CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( TAItK ( 1 02 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED/Q7 2 ( 1 UNKNOWN <br /> 0_CONTAINER CAPACITY_ GALLONS ( i UNKNOWt( JE. DOES THE CONTAINER STORE: ( 1 01 WASTE I -PRODUCT —— <br /> -- <br /> F. D�O�S THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1y1 01 UNLEADED l 1 02 REGULAR l 1-03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL 1 <br /> 06 OTHER - <br /> V CONTAINER CONSTRUCTION — -- — — <br /> A. THICh'NESS OF PRIMARY CONTAINMENT: O. 2- Q ( 1 GAUGE ( CHES ( 1 CM 1 ) UNKNOWN <br /> B. I 1 01 VAULTED (LOCATED III AN UNOERGROUNO VAULT) (402 NON-VAULTED 1 ) 03 UNKNOWN <br /> 1C. I 1 01 DOUBLE W1LLEO ( 02 TIGLE WALLED I 1 03 LINED <br /> ID. 1 I 01 CARBON STEEL 1 ) 02 STAINLESS STEEL t 03 FI6ERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 1 06 ALUMINUM l 1 07 STEEL CLAD t 1 RONZE ( 1 09 COMPOSITE I 1 10 NON-METALLIC <br /> ( 112 UNKNOWN l 1 13 OTHER: <br /> HSC04-0 0185 PAGE 1 <br />