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0 0 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK l <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE_1 <br /> 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NOY�i COPPORATION NCI IDUAL OR FUBIIC AG CY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> ysTaEET ACTRESS C T STATE ZIP <br /> --615- _�� 0� - <br /> II FACILITY <br /> �FACIL,IT,�Y "•E �� DEA ER/FCPEMEN f PERVISO� <br /> �S7REET�CC� — r ��y�--- /� � - NEAP T1 CROSS STREET <br /> An <br /> ITY rr - COUNTY ZIP <br /> F MAILIN OD�ESS �� <br /> CIT STA_ TE ZIP <br /> PHON• W. a CODE JTPF OF BUSINESS <br /> 5 ( GASOLINE STATION ( )__.0 2 OTHER <br /> NUMBER CF CON AINEPS PUPAL AREAS ONLY TOWNSHIP —-- [P.NGE SECTION - -- <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAr,E( LAST NAME FIP ) AND PHONE W/APER CODE NIGHTS: NA E(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH COER <br /> IV DESCRIPTION <br /> A. ( 1 TANK ( 1 02 OTHER: CONTAINER NUMBER -. — <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: FcyEAR INSTALLED � � ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: ,a b, Q(� GALLONS ( ) UNKNOWN ];:�()( SE THE CONTAINER STORE: ( ) O1 WASTE L62 PRODUCT —_ <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ()) 01 YES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t )LEADED ( ) 02 REGULAR t 1 03 PREMIUM ( ) 04 D L ) 05 WASTE OIL ( ) 06 OTHER -- <br /> V CONTAINER CONSTRUCTION - <br /> (A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM ( ) UNKNOWN <br /> IB. ( ) 01 VAULTED (LOCATED IN AN UNOERGROUND VAULT) ( NON-VAULTED ( ) 03 UNKNOWN <br /> {C. ( DOUBLE W1LLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> E0. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l l 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 110 NON-METALLIC <br /> 1 ) 12 UNKNOWN ( ) 13 OTHER* <br /> fa5f.04-00185- - ------ __-------------------- PAGE 1 <br />