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t STATE ID NUMBER 4 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />1 O1 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED t 1 09 OELM FROM FILE (NO FEE) <br />1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAY!(COPPORATION.INOIVIOUAL OR PUBLIC GENCY) <br />STP!ET ACnRESS <br />1515 5 <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />( 1 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br />CITY STATE ZIP <br />FACILITY NAME — <br />f':te - L -a, �-�.-A VD1...-.. <br />DEALE�IR�/f OP EMEN/SUPERVIg1SOP <br />STREET �4 <br />/00--ESS <br />NEAPEST CROSS <br />\E^E'qT 1 <br />SSSTP <br />CITY -- - <br />COUNTY 2IP <br />V aV <br />MAILI`ti AODPES <br />7j 0 <br />CITY <br />�STATTTE— ZIP <br />- -- <br />PMON. W% PEA CODE <br />l.f I� <br />TYPE OfBUSINESS <br />(A O1 GASOLINE STATION ( 1 02 OTHER <br />- _ <br />NUMBS "CONTAYNEPS <br />PUPAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />,AYS: NAME( LAST NAME FIRST AND PHONE W/AREA CODE HIONTS: NAM! LAST NAME FIRST) AND PHONE W/AREA CODE <br />6ewa�r arl - -(1,0-7) as - f 66KC6 VciLhleijvvA6 q a - �Z4 6 l <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />iv (IFSCRTPTTCIN <br />A. ( <br />TANK ( 1 02 OTHER: <br />CONTAINER NUMBER 2 <br />B. MANUFACTURER (IF APPROPRIATE): YEAR MFG. C. YEAR INSTALLED 1 96 6 ( ) UNKNOWN <br />0. CONTAINER CAPACITY: GALLONS ( 1 UNKNOWN JE. DOES THE CONTAINER STORE: 1 1 01 WASTE (d 02 PRODUCT — <br />F. DOES THE CONTAINER TORE MOTOR VEHICLE FUEL OR WASTE OIL ? (/N; 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br />( 1 01 UNLEADED ( 1 02 REGULAR t ) 03 PREMIUM l ) 04 DIESEL 1 ) 05 WASTE OIL 1 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. TkICY.NESS OF PRIMARY CONTAINMENT: ( ) GAUGE (X) INCHES t 1 CM ( 1 UNKNOWN <br />01 VAULTED (LOCATED IN AN UNOERGROUNO VAULT) ('� 02 -NON -VAULTED 1 1 03 UNKNOWN <br />IC. 1 1 01 DOUBLE WALLED tI 02 SINGLE WALLED 1 ) 03 LINED <br />01 CARBON STEEL () 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br />1 06 ALUMINUM 1 ) 07 STEEL CLAD l 1 08 BRONZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br />( 1 12 UNKNOWN l 113 OTHER: <br />+ ' 1.(SC04-0 0185 PAGE 1 <br />. . '. .. - - - .. �c+.+R!Ao.p-.�-erg..•►' <br />