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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ` ( <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED [ 1 09 OELETE' FROM FILE (NO FEE) <br /> I -- CONDITIONAL PERMIT —1 ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE [NO SURCHARGE) —_- <br /> I OWNER <br /> NAME(COPPORATION.INOIVIDUAI R FUBLIC AGEAY) -- PUBLIC AGENCY ONLY -- <br /> ----- — ( 1 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br /> T <br /> STeEET ACQRESS - CITY STATE ZIP <br /> --- - --- �6 9 - - <br /> II FACILITY <br /> FACILITY NAME DEALER/ OPEMENV/SUPER OR <br /> cit j�{'� 1- 6 C�t� 7� � 1 <br /> STREET ADC'ESS NEAREST CROSS STREET <br /> AJ y <br /> CITY COUNSY - 5,53 <br /> d v <br /> 1 MAILING ADDRESS ^ CITY STATE 2IP <br /> _ (J <br /> --�0 `� - - <br /> PHOwE W% C E E CF BUSINESS <br /> ��= S L 1 OHNSTATION ( 1 02 OTHER <br /> NUMBER S PUPAL AREAS ONLY TOWNSHIPPANGS SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY :-NA1E(LAST NAME IPSTI ANO PHON W/AREA CODE NI TS' NAME )AST NAME F RST► VD-PHONE W/AREA COOE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( O1 lK ( ) 02 OTHER CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE D YEAR MFG: C. YEAR INSTALLED ��� < ) UNKNOWN <br /> D. CONTAINER CAPACITY:tD Q -GALLONS t ) UNKNOWN E. GOES THE CONTAINER STR E: ( 1 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINS TRE MOT R VEHICLE FUEL OR WASTE OIL ? () 01 ( 1 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> ( 1 01 U1tLEADED ( 1 02 REGULAR ( ) 03 PREMIUM ( i 04 D=et- 1 05 WASTE OIL ( ) 06 OTHER _- <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( 1 CM l ) UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( lL2-NON-VAULTED ( ) 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WILLED SINGLE WALLED ( ) 03 LINED <br /> D. ( MOON STEEL ( l 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> t 1 06 ALUMINUM l ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER <br /> HSC04-070185 PAGE 1 <br />