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STATE ID NUMBER / <br /> APPLICATION FOR PERMIT TO 05P24 <br /> �A"VE UNDERGROUND STORAGE TANK <br /> L01 NEW PERMIT l 1 05 RENEWED PERMIT 7 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> -P02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ) OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMElCO oORATIO�NOIVIDVAL OR PVBIIC AGENCY) 2PJ�UBICAGENCY ONLY <br /> 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br /> SIRE A.0^R S CK �e CITSTATE ZIP / <br /> c 7_ fl <br /> II FACILITY <br /> FACILITY NAME DIALER/FOREMEN'S PERVISOR <br /> STREET AOCTESS /61NE ARES CROSS STREET <br /> CITY COUNTY ZIP <br /> MAILING AOOPESS CITY` ST E ZIP <br /> 2 ( J rX <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> - ( 1 <br /> 01 GASOLINE STATION C)4)_,p2 OTHER <br /> NUMBER CF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM (LAST NAME FIPST) AND PHONE W/AREA CODE NIGHT$: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> KEu <br /> � aoy- ► �9� Kin=`�nttno <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TAMC f 1 02 OTHER) CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): kLkYEAR MFG: C. YEAR INSTALLED t ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE l ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (V_01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR f ) 03 PREMIUM ()el04 DiENTIL ( 7 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( ) INCHES ( ) CM 111, UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X7 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 3 02 SINGLE WALLED l 1 03 LINED ((M"o(dt4 <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> y)( ) 06 ALUMINUM 1 ) 07 STEEL CLAD f ) 08 BRONZE ( 1 09 COMPOSITE ( 1 30 NON-METALLIC <br /> _!J) 12 UNKNOWN ( ) 13 OTHER: <br /> HBC04-070185 PAGE 1 <br />