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• �"� �+ STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUNDSTKiTt �_., <br /> 1X1 01 NEN PERMIT 1 .1 05 REN M71PERMIT t -1 07 TANK CygEEO (, 1,¢� RlLETC fRIR1 RILE.(�tD, FEET <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 04 MINOR CHANSE (No 0t1RCNAR0E1 = <br /> I OWNER <br /> HAMIICOtP�PORATION.INDIVIOUAL oRL Plb IC AGENCY$ PUBLIC AGENCY ONLY <br /> 6t��tN V1/�Lole [ t0 r 1u 1 N 01 FED 1 1 OL STATE t 1 oi,LOCAL <br /> STREET AC7rl - <br /> ` : etr srxt ZI 7 -a i L7 <br /> II FACILITY - <br /> FACILITY NAME OEALER/FOPEMEN/SUPERVISOR <br /> how <br /> STREET ADD-ESJ + HEAREST CRGMS STREET fu <br /> 2.Nh.o l//).l�(Y1t <br /> CITY ^ rc�C�C 1UNTyII./,�203 <br /> MAINING ADDRESS <br /> hYY-N'la� C VI1'�l(J(�� Dn In... fTA,rE 1g6��2Q3 ' <br /> PH Clop/e rrreof Ous:Ness <br /> tel. Volo — b�3 l 1 OF GASOLINE STATION 1 02 OTHER <br /> NUMGEs OF CO TA INPIs RURAL AREAS ONLY TOWNSHIP LANCE SECTION <br /> _._M_—_ <br /> III 24 HOUR EMERGEN(�C, L_1I�I <br /> Y CONTACT PERSON '/j[ <br /> DAY NAR LASTNAME �M P TIAND��PMObL-013CI NIGHTS:� vQ- Sko NI'If"1T RSTI AND AREA COOE <br /> /�lJ''1 <br /> � <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> A. ( 01 TANK ( 1 02 OTHER- CONTAINER N"ER <br /> B. MAWFACTURER (IFS APPROPRIATE$: _. YEAR MFG: C. YEAR INSTALLED I�..}-�{. 1 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: ��O GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE 1 02 PRODUCT <br /> F. DOS THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (>I 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOKIESI: <br /> 1 01 UtLEAOED 1 1 02 REGULAR 1 1 0 PREMIUM) l 1 04 DIESEL 1 1 OS HASTE OIL 1 1 06 OTHER <br /> V J� CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 1 INCHES ( ICM l� IMKNOWN <br /> B. 1 1 01 VAULTED (LOCATES IH AN L040ERGROLP40 VAULT) '1 1 02 NON-VAULTED 1 OS UNKNOWN <br /> IC. 1 1 01 DOUBLE W4LLED 1X1 02 SINGLE WALLED 1 1 03 LINED <br /> O. 1 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE 1 1 OS CONCRETE <br /> ( 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 06 BROIZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> -..-1X) 12 UNKNOWtI l 1 13 OTHER <br /> HSC04-07018S PAGE 1 <br />