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STATE IO NUM3F.0 <br /> APPLICA'rION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1X1 O1 NE:7 PFRi:IT ( ) 05 RENEWED—FLP.MIT ( ) 07 TAIK CLOSED ( ) 09 DELETE FPDM FILE (NO FLE) 1 <br /> 02 CLNDiTIONAL i'ERMIT f 1 06 AMEh7E0 PERMIT ( ) 06 MINOR CHANGE (NJ SL)RCHARGE) JI <br /> I OONEP, <br /> MEICQRP�OPF'ICF,IN� 01DUAL OR PUBLIC AGEN >�j^� �— PUBLIC AS-tiC( ONLY <br /> � <br /> --_--I'1-1� — CLB 1 � l ? 03 FID ( ) 02 STATE ( ) 03 LOCAL <br /> �5'REI'T ADO.^ESS CI 1' S7yTE � S --- <br /> L-_ 1= �UYJI l S ff' L 7 <br /> II FACILT_TY <br /> FACILITY I4AME <br /> i DEALER/FOREM+ /SVPE� <br /> Arc, /)OLV( d <br /> a A <br /> jSTPEET AD_DY.:ESS d NEAREST rS STR F,ET <br /> IC'.TY r - COU N Y A\ ZIP <br /> __ <br /> jraIIING A9 ESj � CITY 1 STATE Z' 7m� �Y <br /> �F4012� COD E`- J TYP OF BUSINESS <br /> (�j ) <br /> 01 GASOLINE STATION ( ) D2 OTHER <br /> OF CCNTAIEEPS RUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> L <br /> 1II 24 HOOP EMrRGENCY CONTACT PERSON <br /> ---- - --- ---- <br /> r4iS: NAMF(LAST NA% F7:'ST AND PHONE W,'A(R�E.A"�C COE NIGHTS: NAM{/([/�LA.ST NAME FIRST) A(/yIOFMON Ni ARE COJ4 ' <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACI4 CONTAINER <br /> 1V DESCRIPTION <br /> A. :Xt OS TANK ( 1 04 OTHER: - CONTAINER NUMBER 3 <br /> 1 <br /> B. MANLIFALTURER (IF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLEDj ( ) UIO:N01S4 <br /> t <br /> L•. CONTAINER CAPACITY: ��;Z'y'� GALLONS ( ) UrMNOIiN E. DOES THE CONTAINER STORE: ( ) 01 WASTE V 02 Pi20DUCT � <br /> F. DOES THE L'OHI AINCR TORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X1,81 YES f ) 02 NO IF YES CHECK APPROPRIATE DOY.(ES): ) <br /> ( 1 01 UNLEADED 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEEL ( ) 05 WASTE OIL 06 OTHER j <br /> -t <br /> V CONTAINER CONSTRUCTION <br /> !A. THICI:NE55 OF PRIMARY CONTAItTIE)JT: D 2,91C) ( 1 GAUGE HES ( ) CM ( ) UIM401414 <br /> E. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND.VAULT) (]CO2 143N-VAULTEDl ) 03 UNKNOLN <br /> C. l 101 DOUBLE WALLED (�SIN3LE WALLED l 103 LINED j <br /> ID. (',VOl CARBC.Z STEEL ( 1 02 STAIY.LEES STEEL l 1 03 FIBCI7GLASS 1 ) 04 POLYVINYL CHLO13DE ( ) 05 CONCR.TE <br /> 1 06 ALV'!-NUM l ) 07 STEEL Cgj Ll [ 1 06 BRONZE l ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> l ) 12 LC7KNOt01 l ) 13 OTHER: <br /> P5:04-070105 PAGE 1 <br /> i <br /> I <br />