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• • STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND ST6E, IIL .aF <br /> t, t at fN.'�ER1ltt ' ' . °'? '1 ' l 1 OS RENEWED IERMITf 1 07 TANK CtASEO # 4 OELET!!,f,ROMIL ,tlQ FEEi <br /> 1 1 Of CONDITIONAL PERMIT f 1 06 AMENDEO PERMIT f 1 OO MINOR CHANGE (NO SURCHARGE) , <br /> I OWNER <br /> NaMEtCOPPORATION•INDIVtOUAL OR P tie AGENCY) PUBLIC AGENCY ONLY <br /> f /Ra. �f9 1 1 01 FED 1 1 O2 STATE ,f ? Q3,LOCAL <br /> S <br /> CITY STATi a, 3s w . <br /> II FACILITY ,. , ,� t10 4 <br /> FACILITY NAME ' l f .� DIALER/POrIMLN�SVPERVISOR <br /> STRCIT A009tst NCARtST CROs$ STREET <br /> CITY COUNT ZIP <br /> n,sllNo Aoortss f3. J � - elYr ` STATE, <br /> PHONE W%Arta COOL <br /> TYPE OF WSiNEit <br /> 1 01 GASOLINE STATION (! 11O2 OTHER <br /> HLWSCR OF :CONTAINERS RURAL AREAS ONLY: TOWNSHIP PANOE flCTZOK <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAKlfLAZT "AMC FIPSTI AND PHONE W/AREA COO! NIONTSt 1NAM94LA:T "AMC FIRST) ANO.PHONE W/AREA COOE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />�f A. (,W61TANK ( 1 02 OTHER: - CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE) _ �--y _._ YEAR MFG= C. YEAR INSTALLED F7 ( ,1 UWJ40 M <br /> 0. CONTAINER CAPACITY:/ a GALLONS 1 1 UNKNOWNE. DOES THE;CONTAINER STORE: ( 1 01 WASTE -( 2, PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? f 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BO%IES1: <br /> ( 1 01 Ut1LEA0E0 ( REGULAR= t 1 03 PREMIUM <( 1 04 DIESEL l 1 OS WASTE OIL I 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE f 1 INCHES I .1 CM l%,A'UwHOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNOERGROUfID VAULT) '(440102 NON-VAULTED 1 1 03 UNKNOWN <br /> iC. 1ZOIOUBLE WALLED ( ) 02 SINGLE WALLED 1 1 OS LEO <br /> 0. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL t 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 OS CONCRETE <br /> ( 1 06 ALUMIt1UM l 1 07 STEEL CLAD_t 1 06 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWtl ( 1 13 OTHER: <br /> +IiL04-0:0185 ---------- --- -- ------------ ----- PAGE 1 <br />