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�Tu1 <br /> STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT ( 1 OS RENEWED PERMIT ( 1 07 TANK CLOSED t 1 09.OELETE FROM FILE (NO FEE) <br /> 1 1 02 CO1l0ITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 00 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAM!ICOPPORATION, IV DUAL OR PUBLI97AGENCYI -------------- PUBLIC AGENCY OMIT -----'--------. -- <br /> ----- / 1 01 FED l 1 02 STATE (,(1 03 LOCAL <br /> [C Y <br /> e:zACL` may_ <br /> II FACILITY �J <br /> /ACIIITr NAME�— � � OEAIIR/I�P�SVPERVISOp - <br /> STPEET ADDIESS ^� NEAREST CROSS STPEET <br /> CITY �� couyT ZIP <br /> MAILING AOOPESSCITY STATE ZIP <br /> ►HON! W•ACEA CODE TYPE OF OUSINESS <br /> - UGf cc 3 C7 01 GASOLINE STATION 1 1 02 OTHER <br /> NU)'EER CF CONTAINEPS - PUPAL APEAS ONLY : TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> 0AY4: NAMEtLAST NAME PIPST) AND PHONE W/AREA CODE J�NIGHTS, NAMEILAST NAME FIRST) AND PHONE W/APER CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (` 01 TAW ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE 1: YEAR MFG:--) C. YEAR INSTALLED Z ( 1 UNKNOWN <br /> 0. C014TAI14ER CAPACITY: o(pC�)GALLONS ( l UNKNOWN E. GOES THE CONTAINER STORE l 1 01 WASTE l 02 PRODUCT <br /> F. DOES THE CONTAI14EP STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> 1 1 01 U::LEADEO ( 1 02 REGULAR ( 1 03 PREMIUM (Kl 04 DIESEL l 1 OS WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THTCYNFSS OF PP.IMARY CONTAINMENT: 1 GAUGE 1 1 IIICHES ( 1 CM 1 1 UNKNOWN <br /> 18. ( 1 01 VAULTED (LOCATED IN Atl UtIOERGROUIID VAULT 1 -r-A 02 NON-VAULTED 1 1 03 UNKNOWN <br /> IC. I 1 01 DOUBLE WILLED 102 SINGLE WALLED 1 1 03 LIt1EO <br /> �D.-(�6 01 CARBON STEEL 1 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIOE ( 1 OS CONCRETE <br /> ( 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 08 BRONZE I 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWtl ( 1 13 OTHER: <br /> Ir,S PAGE 1 <br />