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• • STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />0 EW PE@MIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />F�( 2 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />I.' <br />AM!rCOP0CRATION.,TNCIVIDU4L OR PUBLIC GEN Y) 1 <br />STPEET AC^KESS <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />I`ITIP <br />r1� A - n"- ICJ, IS( T� IZ 6) <br />° f4CItTTr NAME <br />DEALER/FO EMEN/SUPERVISOP <br />`STREET ACCESS <br />NEA4E T CROSS TPEET <br />�� <br />a <br />,CITY <br />COU <br />Y <br />ZZ <br />L Yom. <br />MAILING AD PESS <br />CITY <br />STATE <br />ZI <br />O <br />/P A CODE <br />TYPE OF BUSINESS 'TIO <br />1P�MOA _ �. �`w <br />�RS1 <br />O1 GASOLINE STATION <br />( 1 02 OTHER <br />—`+',► <br />NUf DER`"Cf"Cn?4r Tv4.eRS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />PANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />(DAYS: N ME(LA.ST NAMEZPST) A ON W EACODENIGHTSNAMET�AME FIRST)-AN�VHONE�W/AEA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. 1 01 TA)(K ( 1 02 OTHER: CONTAINER NUMBER 4- <br />B. MANUFACTURER <br />- <br />B.MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED <br />( ) UNKNOWN <br />D. CONTAINER CAPACITY: dGALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( 1402 PRODUCT <br />F DQES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? YES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)- <br />01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( l 04 DIESEL ( ) 05 WASTE OIL (x 06 OTHER CCSaf�Kt <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PP,IMARY CONTAINMENT (rji Z SO ( ) GAUGE ( h{GREs <br />( ) CM ( ) UNKNOWN <br />B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (J4 02 -NON -VAULTED ( l 03 UNKNOWN <br />C. ( ) 01 DOUBLE WILLED (A 02 SINGLE WALLED ( ) 03 LINED <br />ID. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL (.•.03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BOONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br />12 UNKNOWN ( ) 13 OTHER: <br />H5C04-070185 <br />PAGE 1 <br />