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APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> XI NEW PERMIT 1 1 05 RENEWED PERMIT ( 1 07 TAN( CL05EO 1 1 09 DELETE-FROM FILE INO FEE) <br /> 2 COIIOITIONAL PERMIT _1 1 06 AMENDED PERMIT _ 1 1 OB MINOR CHANGE IND SURCHARGED <br /> I OWNER <br /> N.M•ICOC/*q#ATIO,N..IN)I`VIOUAL OR ►YOLK AGENCY) PUBLIC AGfKY ONLY <br /> eLf_6 /J GICTS Zni� _-_ 1 1 01 FEO 1 1 02 STATE 1 1 03 LOCAL <br /> STPEEI AOnR[SS CITY STATi zIP <br /> /w/y �'�� FT <br /> II FACILITY <br /> FACILITY N E OCALCR/I CM[N/SVPCPVIsop <br /> V Y M <br /> iiP([T aOC1CST NCACEST CROSS STPECT <br /> CITY �� COUNTY✓/ 7- ► <br /> n.ItlNozylDoOrEss �6-,)K C 3 9 -7c TY S7 srATi -1-- zi "s-LO / <br /> PNONC W+ACCA CODES TYPE OC RUSIN(ss •L7 <br /> Fj -76 6 1 1 01 GASOLINE STATION 1 1 02 OTHER <br /> MIA'R[R CP CONTAIN PT RUPAL ^PEAS ONLY : TOWNSHIP PANGC SECTION <br /> II1 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: HAMCILAST NAME PIPSTI AND PHONE W/AICA COOL NIGHTS: NAMEILAST N ME FIRSTI AND PHONE W/APIA COOK <br /> �A.e <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (N 01 TALE( 1 -1 02 OTHERS CONTAINER NUMBER <br /> 5. HJUUFACTURER IIf APPROPRIATE I: vNk YEAR MFG: C. YEAR INSTALLED IAS UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS 1 1 UNKHONI E. DOES THE CONTAINER STORE: 1 1 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAIIIEGTORE MOTOR VEHICLE FUEL OR WASTE OIL ' 1 1 01 YES 1 1 02 NO IF TES CHECK APPROPRIATE BO%IES1: <br /> 1 1 01 U:ILEADCO 9C1 02 REGULAR 1 1 03 PREMIUM ( 1 04 DIESEL l 1 OS WASTE OIL ( 1 06 OTHER <br /> V CONTAINERCONSTRUCTION <br /> - -- --- -- ------ <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE 1 1 INCHES 1 1 CM UNKNOWN <br /> 8. 1 1 01 VAULTED (LOCATED III ATI UHOERGROUIID VAULTI / 1 02 NON-VAULT EO 1 03 UNKNOWN <br /> JC._I 1 OI DOUBLE WALLEO Yv 02 SINGLE WALLEO 1 1 03 LII/EO <br /> D. Iv 1 01 CARS011 STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE . <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD ( 1 06 BROIIZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 12 LRIKNONI ( 1 13 OTHER: <br /> HSC04-070185 —-- - <br /> PAGE 1 <br />