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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO UNDERGROUND STOR E TANK <br /> ISt✓01 NEW PERMIT 1 ) 05 RENEWED PERMIT 1 07 TANK CLOSED I'l1 09.OELETE FROM FILE INO FEEI <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 00 MINOR CHANGE IND SURCHARGE) <br /> I OWNER <br /> NAY. coP P�(gpATIO'}�2 NOIV iOutl OR pUDI IC AOENCYI PUBLIC AGENCY ONLY <br /> J �• -ot'fec�C O/ls _—_ __ ____ ( 1 01 FED O%C"2 STATE 1 1 03 LOCAL <br /> STPEET AO9IC33 CIT STAT! TZIP <br /> c ra.n\.,e40 �� 19 <br /> II FACILITY <br /> PACIL NAME A ti DEALER/FOPEMEN, UPEPVISOP <br /> c2ue��e�.l�cona.� 51 1 a`� o Jerr �cl co . c -- <br /> STFEET AOMESS NEAPEST CROSS STREET <br /> 2_ama7 /556n L -.5- <br /> C' <br /> s <br /> c-T0. cOUNTv <br /> C T <br /> oa EE. - IIP — <br /> 953 <br /> PAILS /� Q <br /> A1DOPF/� �/�Ty�S CITY ST TC ZIP <br /> ►MON! W'AREA CODE TYPE Of DUSINESS ''II I 11 / <br /> 9 y3� Yip// �>�• Y_. ( a _i6*r 01 GASOLINE STATION K 02 OTHER 6x-rencU SYI�W�r01 <br /> NVYDCp C• CONTAINERS --- PUPAL AREAS—ONLY : TOWNSHIP PANOC — SCC TION <br /> 12, <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> LAYS: NAY,E,IAST NAME PIPSTI ANO PHONE W/AICA COD! ��IONTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> 3f-t9Y1 &,,AY.Z% ig_ A&C_01 Terr�r Z01-9.35-YlY/ Y2f'� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ()f-01 TANK l I 02 OTHER_ _ -- — CONTAINER NUMBER <br /> B. MANUFACTURER IIF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLED/(7;L ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: '3 GALLONS f 1 UNKNOWN E. ODES THE CONTAINER STORE: ( 1 01 WASTE Oki 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ' lkl 01 YES l ) 02 NO IF YES CHECK APPROPRIATE BOKIESI: <br /> 1 1 01 UNLEADED ( 1 02 REGULAR ( 1 03 PREMIUM V¢T 04 DIESEL 1 ) 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> �A. THICKNESS OF PP.IMARY CONTAINMENT: /Q 00 GAUGE 1 1 IHCHE5 1 1 CM 1 1 UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNOERGROUND VAULT Vlf 02 NON-VAULTED _ 1_I 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE WILLED 04r) 02 SINGLE WALLED 1 1 03 LINED ---_ - - - <br /> D. 04 01 CARBON STEEL 1 1 02 STAINLESS STEEL / 1 03 FIGERGLASS 1 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( 106 ALUMINUM 1 ) 07 STEEL CLAD 1 1 OD BRONZE I 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN ( 1 13 OTHER: <br /> NDC04-0;^105 - - - - - PAGE 1 <br />