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we*-4- l <br /> STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> [— <br /> 1 O1 NEW PERMIT ( 1 OS RENEWED PERMIT ( 1 07 TANK CLOSED ( 1 09.OEtETE FROM FILE (NO FEE) <br /> 02 COWITIONAL PERMIT ( 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INCIVIOUAL OR PUBLIC AGENCY) ------—-- — PUBLIC AGENCY ONLY ----_ - – <br /> / 1 01 FED ( 1 02 STATE l 03 LOCAL— <br /> fielLT AC'1R!$S CITY _ j�T TE ZIP <br /> II FACILITY <br /> FACIIITi NAME DEALER/FOPEMEN�IVPERVISOR _ <br /> STPEET ACD'ESS NEAREST CROSS STPEET <br /> CITY COUNTY ZIP <br /> 3 CD <br /> MAILING AOOPESS CI 4,� ST�E` ZI� c <br /> PHON! W•ACEA CODE TYPE OF BUSINESS <br /> —m3 0, <br /> -62 VA 01 GASOLINE STATION ( 1 02 OTHER <br /> NUr5ER CF CONTAIINEPS PUPAL APEAS ONLY ; TOWNSHIP PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIPST) AND PHONE W/APEA CODE NIGHTS: NAME) ST NAME FIRST) AND PHONE W/APEA CODE <br /> a <br /> L3l i -i -'177 Ac,y-3 - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (s4 01 TAW ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MA14UFACTUP.ER (IF APPROPRIATE): YEAR MFG:�� C. YEAR INSTALLED l���t 1 UNKNOWN <br /> 0. CONTAINER CAPACITY O(D GALLONS t 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 HASTE t-- 1 02 PRODUCT <br /> F. DOES THE CONTAI14EP STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 01 U::LEADEO t)(,1 02 REGULAR l 1 03 PREMIUM ( 1 04 DIESEL l 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> ---------- <br /> A. <br /> ---------A. THICY►IESS OF PP.IMARY CONTAINMENT: 1 1 GAUGE ( 1 INCHES 1 1 CM l�1'UNKNOWN <br /> IB. ( 1 01 VAULTED (LOCATED IN AN UNOERGPOUNO VAULTI PwJ, 02 NON-VAULTED t ! 03 UNKNOWN <br /> !C. 1�1 01 DOUBLE W1LLE0 (-t-j 02 SINGLE WALLED 1 1_ 0-3 LINED <br /> i0. 01J 01 CARBOtI STEEL l 1 02 STAINLESS STEEL ( 1 03 FICERGLASS t 1 04 POLYVINYL CHLORIDE ( 1 05 CONCPETE <br /> t 1 OP ALUMINUM 1 1 07 STEEL CLAD 1 ! 08 BRONZE t 1 09 COMPOSITE l 1 10 t4m4-METALLIC <br /> ( 1 12 Ut,Y.NOWfl ( 1 13 0THER: ` <br /> Ii5COG-0;"IP5 PAGE 1 <br />