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APPLICATION FOR <br />MIT TO OPERATE.UNDERGRO <br />STATE ID NUMBER <br />STORAGE TANK <br />(✓T DI NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE1 <br />( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br />STREET ADDRESS <br />[I FACILITY <br />FACILITY NAME <br />? <br />DEALER/POPE N!SU PVISOP <br />STREET ADDRESS <br />NEAREST CROS TPEET <br />CItY � <br />COUNTY <br />IIP <br />MAILING ADDRESS., <br />CITYSTA <br />E <br />IIP <br />/� <br />/•C`• <br />PHONE WiAFEA CODETYPE <br />OF BUSINESS <br />GASOLINE STATION (4-1-62 OTHER <br />NUMBER OF CONTAINERS <br />PUPAL AREAS ONLY <br />TOWN IP <br />RANGE <br />SECTION <br />/ <br />y: QUI <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: MEt S NA FIP.ST) AND PHONE W/AREA CODE NIGHT : NAME AST NAME FIRST) AND PHONE W/AREA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (TANK ( 1 02 OTHER: CONTAINER NUMBERv +,I' <br />B. MANUFACTURER (IF APPROPRIATE): �jL7/?�,;�j/ /�� j�/>•G. YEAR MFGy/'V& C. YEAR INSTALLED,,,� ( 1 UNKNOAR <br />D. CONTAINER CAPACITY: Lrlll) GALLONS ( ) UNKNOWN JE. DOES THE CONTAINER STORE: ( ) 01 WASTE ( I -T2- PRODUCT <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL t T^`O1 TES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( 1 01 UNLEADED ( 1 02 REGULAR ( ) 03 PREMIUM ( Y04 DIESEL t 1 05 WASTE OIL t ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PRIMARY CONTAINMENT: ( J GAUGE ( CINCHES ( ) CM ( ) UNKNOWN X�61 <br />B. ( 1 01 VAULTED (LOCATED IN AN U(lDERGROU)lD VAULT) (t4-12 NON -VAULTED t ) 03 UNKNOWN <br />IC. ( W'Oi DOUBLE WALLED t ) 02 SINGLE WALLED ( 1 03 LINED <br />'D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( 1 06 ALUMINUM (L1-07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br />( 1 12 UNKNOWN ( ) 13 OTHER: <br />ISC04-070185 PAGE 1 <br />0 <br />