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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAHEIC PPORATIO�jNCIYIDUAL QR PVDIIC AGENCY) PUBLIC AGENCY ONLY <br /> l ) Ol FED ( 1 02 STATE l ) 03 LOCAL <br /> STREET ACTRESS CI; STATE ZIP <br /> ViiJ7�L <br /> II FACILITY <br /> FACILIT NAME DEALER/FOPEMEN�S VPERY SOR <br /> Tn�x <br /> STREET ACO�E NEAREST CROSS STREF <br /> 70 <br /> CITY - COVNT� ZIP <br /> MAILING ADDRESS CITY !' STATE ZIP <br /> ,V&: <br /> PHONE w/A�• LODE TYPE1 OF BUSINESS ou <br /> 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYI: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LASj� NAME FIRST) AND PHONE W/AREA CODE <br /> 6w& -?yfT4o74�3 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. jj 01 TANK ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): E�/'TF--Rnl /Y��T-AZZ- YEAR MFG: C. YEAR INSTALLESjfZ7_l ) UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS l ) UNKNOWN E. DOES THE CONTAINER STORE: 1 1 O1 HASTE (�1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXl ES 1: <br /> (TES <br /> UNLEADED ) 02 REGULAR ( ) 03 PREMIUM t ) 04 DIESEL ( 1 05 WASTE OIL [ 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES ( ) CM (,y4 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Z-4 02 NON-VAULTED ( ) 03 UNKNOWN <br /> 1C. ( 1 O1 DOUBLE WALLED ( ) 02 SINGLE WALLED l 1 03 LINED <br /> D. l ) 01 CARBON STEEL l ] 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br /> 1 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> 12 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />