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6A o/esu .�s r�1 6- 6 <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( 1 07 TANK CLOSED 1 1 09 DELETE' FROM FILE INO FEE) <br /> 02 COIIOITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAr.!JCOPPORATION,INDIVIDUAI OR FU5LIC AGENCY) ONLY <br /> � ^� N �� � ���PUS�LICAGENCY <br /> D ( 1 02 STATE ( 103 LOCCALSTP!17 ACI)RLSS IA7, Ip CITY -S/ -!�'�"rr-�G.�FV�v JST.Tl ZIP <br /> II FACILITY <br /> FACILITY NATE �= DEALER/FOPEMEN>SUPERVISOP <br /> STPEET ADC-ESS �s NEAPEST CROSS STPEET <br /> CITY COUNTY IIP <br /> IwAILINO ADOPESSCITY � } STATE IIP �a-7-77 J <br /> S Z71 : <br /> PNON, W•APEA CODE TYPE CF SUSINESS <br /> ( 1 01 GASOLINE STATION 02 OTHER cJG1 { #� •7 /L <br /> NUrSEP CF C9NTAINEPS PUPAL APEAS ONLYTOWNStiIP PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> PAYS: NAME(LAST NAME FIPSTI AND PHONE W/APEA CODE <br /> s E NIGHTS: NAME(LAST NAME FIRST) AND PHONE WAR" CODE / <br /> G-+ tr✓Q'e�2 /v)( '�� Via_ 1 �'TT�P� 1 / �� �//✓/��.^�? � -� — z3'�J�(7 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />,h <br /> A. 1A(i O1 TAtrK 1 1 02 OTHER: CONTAINER NUMBER ca <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLEDr 1 } UNKNOWN <br /> 0. C014TAIIIER CAPACITY= I.Ja4pGALLONS ( 1 LMKNOiRI E. DOES THE CONTAINER STORE: f 1 01 WASTE l 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ' ( 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> I 1 01 UNLEADED I 1 02 REGULAR ( 1 03 PREMIUM (XI 04 DIESEL ( 1 05 WASTE OIL 1 1 05 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PP.IMARY CONTAINMENT: ( I GAUGE ( 1 INCHES ( ) CM l ) UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN U140ERGROUIO VAULT) ( 1 02 NON-VAULTED 1 1 03 UNKNOWN <br /> JC, ( 1 01 DOUBLE WILLED 02 SINGLE WALLED 1 1 03 LINED <br /> ID. INI.,74 CARBON STEEL f 1 02 STAINLESS STEEL -t-1 03 FIBERGLASS S 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> l 1 06 ALUMINUM 1 1 07 STEEL CLAD f 1 08 BRONZE I Y 09 COMPOSITE t i 10 NON-METALLIC <br /> 1 1 12 UNKNOWN l 1 13 OTHER: <br /> PAGE 1 <br />