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• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERAJE UNDERGROUND STORAGE TANK <br /> 1 01 NEN PERMIT t 1 OS RENEWED PERMIT t07 ANK CLOSED t 1 09 DELETE' FROM FILE (NO FEET <br /> 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT 1 )08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> HAM!(C_ OPDORATION NO VIDUAI OR fUlsllC OIN� - PUBLIC AGENCY ONLY - <br /> ( ) 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS c CI,T STATE ZIP <br /> II FACILITY <br /> FACILITY�NAME AF �� OE AIER/FOPIMEN� RVISOP <br /> a� r - — <br /> STREET a NEADES CROSS STREET <br /> CITY 64z COUNTY Y ZIP <br /> MAItING„AODPESS CITY STAT! <br />... i � <br /> PHONE WARE• CODETVP OF EUSIN'.SS <br /> LlO1 GASOLINE STATION ( 1 02 OTHER <br /> NUHpER CF coN A2NERS PUPAL AREAS ONLY ; TOWNSHIP PANGS SCCTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME Ft P T) AND ^NO►1� W/APEA CODE��� NIGHTS: NA 1 LAST MI�MEE FIRST) ANDS TZ W�R�EA COO <br /> 00 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />. A. (x O1 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEI: YEAR MFG: C. YEAR INSTALLED ( w UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLOIIS ( — LWAlOWN E. DOES THE CONTAINER STORE: (XI-201-WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 1 YES 1 ) 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> -I 1 01 UNLEADED ( 1 02 REGULAR ( 1 03 PREMIUM- ( 1 04 0 -SEL l 05 WASTE OIL -l' a06_OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICY.IIESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 IIICHES ( I CM lX UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNOERGROUND VAULT) ) +-f2 NON-VAULTED (x) 03 UNKNOWN <br /> (C. !, . 01 DOUBLE WILLED ( 4Y- Q2 SINGLE WALLED__(_ )_ 03 LINED <br /> 0. l 1 O1 CARBON STEEL ( 1 02 STAINLESS STEEL ( t 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br /> ( 1 06 ALUMINUM 1 ) 07 STEEL CLAD 1 1 08 dROt1ZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ()qlELNKNOWtl l 1 13 OTHER: <br /> HSCO -070185 PAGE 1 <br />