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STATE ID NUMBER <br />APPLICATION ,FORORMIT TO OPERATE UNDERGRO* STORAGE TANK <br />(,.401 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED L I uy uctcic rKUrl FuaL .+ <br />( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br />INDIVIDUAL OR PUB <br />STREET ADDRESS <br />T T TTV <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS�NILAST N E FIRST) AND PHONE W/AREA CODE NIGHTS: AM (LAST NAME FIRST) AND PHONfE,W/AREA CODE <br />R - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />r r r r n T o T 7 n Al <br />jFACIIITY NAME <br />'o <br />DEALER/FOREMEN/S ERVI <br />A. <br />( q, 01 TANK ( ) 02 <br />OTHER, <br />CONTAINER NUMBER <br />B. <br />STREET ADD?ESS <br />NEAP,EST CROS EE <br />YEAR MFG h <br />C. <br />YEAR INSTALLED//j _ t <br />l UNKNOWN <br />D. <br />CITY <br />',''( GALLONS ( ) UNKNOWN <br />COUNTY r .—""— <br />ZIP <br />_ <br />F. <br />,I— <br />STORE MOTOR <br />VEHICLE FUEL OR WASTEyOlt ? (4A`O1 <br />YES ( ) 02 NO <br />IF YES CHECK APPROPRIATE <br />CITY <br />STA E <br />ZIP <br />MAILING ADDRESS_ <br />( ) 03 PREMIUM (y'f' 04 DIESEL <br />( `) 05 WASTE OIL <br />t ) 06 OTHER <br />J� <br />PHONE W/A.FEA COD <br />TYPE OF BUSINESS <br />01 GASOLINE STATION (iX02 OTHER <br />NUMBER OF CONTAINE%P.S <br />RURAL AREAS ONLY : <br />TOWN NIP <br />RANGE <br />SECTION <br />/ 3 <br />/ <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS�NILAST N E FIRST) AND PHONE W/AREA CODE NIGHTS: AM (LAST NAME FIRST) AND PHONfE,W/AREA CODE <br />R - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />r r r r n T o T 7 n Al <br />V CONTAINER CONSTRUCTION <br />IA. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE (4J. INCHES ( ) CM ( ) UNKNOWN o�,� - <br />IB. ( 1 01 VAULTED (LOCATED IN AN U14DERGROUND VAULT) (c4-02 NON -VAULTED ( ) 03 UNKNOWN <br />iC. ( 4-10-1 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br />D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 06 ALUMINUM (&,Y-'07 STEEL CLAD ( ) 08 BRO))ZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br />( ) 12 UNKNOWN ( ) 13 OTHER: <br />HSC04-070185 <br />rAUr a <br />r <br />A. <br />( q, 01 TANK ( ) 02 <br />OTHER, <br />CONTAINER NUMBER <br />B. <br />MANUFACTURER ( IF APPROPRIATE): <br />i' /r✓DGY '%/ "� %��G <br />YEAR MFG h <br />C. <br />YEAR INSTALLED//j _ t <br />l UNKNOWN <br />D. <br />CONTAINER CAPACITY:. <br />',''( GALLONS ( ) UNKNOWN <br />JE. DOES THE <br />CONTAINER STORE: ( <br />) 01 WASTE ( PRODUCT <br />F. <br />DOES THE CONTAINER <br />STORE MOTOR <br />VEHICLE FUEL OR WASTEyOlt ? (4A`O1 <br />YES ( ) 02 NO <br />IF YES CHECK APPROPRIATE <br />BOX(ES): <br />( ) 01 UNLEADED ( <br />) 02 REGULAR <br />( ) 03 PREMIUM (y'f' 04 DIESEL <br />( `) 05 WASTE OIL <br />t ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />IA. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE (4J. INCHES ( ) CM ( ) UNKNOWN o�,� - <br />IB. ( 1 01 VAULTED (LOCATED IN AN U14DERGROUND VAULT) (c4-02 NON -VAULTED ( ) 03 UNKNOWN <br />iC. ( 4-10-1 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br />D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 06 ALUMINUM (&,Y-'07 STEEL CLAD ( ) 08 BRO))ZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br />( ) 12 UNKNOWN ( ) 13 OTHER: <br />HSC04-070185 <br />rAUr a <br />r <br />