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77 <br /> i <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT l 1 07 TANK CLOSED ( 1 09 DELETE• FROM FILE (NO FEE) <br /> 02 COHOITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE IND SURCHARGE) <br /> OWNER <br /> OPPO-E) RATION DUAt 09 Pu AGCY 1J, � T PL(BLIAGENCY ONLY — <br /> ( 1 O11 FED i 1 02 STATE ( 1 03 LOCAL <br /> PCCT ACRRESS CIT STATE ZIP <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMENISVPEPVISOP <br /> S'FEET ADC"fS5 - NEAREST CROSS STPEET <br /> CITY COUNT ZIP �J 3 <br /> p ?G/Gd ' e TJ_ ✓ a <br />�1 AILING��AODpt55 ` CITY STATE Z P S Zf <br /> ___L"c��_ O 2-/ 4 --���` ����✓''['r Q� <br /> PHONE W•ACEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION (A 02 OTHER Q t-f 7,44 ��/C_ <br /> NUMBER Cr CONTAINEPS PUPAL APfAS ONLY Fow(SKIP RANGE SECTION <br /> --- ---rte--- -- — <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIPSTI AND PHONE W/AREA CODE NIONTS: NAME(LAST NAME FIRST) AND PHONE W/AR A CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> K A. q ' 01 TAfiK { 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEI: YEAR MFG: C. YEAR INSTAtk6 1 1 UNKNOWN <br /> 0. CONTAINERCAPACITY: rQ 6 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE ROTOR VEHICLE FUEL OR WASTE OIL ? ( 101 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> �yi 1 01 UtILEADEO ( 1 02 REGULAR ( )_03 PREMIUM4 DIESEL 1 1 05 WASTE OIL ( 1 O5 OTHER- --_ — _-- <br /> V CONTAINER CONSTRUCTION <br /> A. THICY.tIESS OF PRIMARY CONTAINMENT: ( I GAUGE 1 I INCHES ( 1 CM ( ! UNKNOWN <br /> 1 01 VAULI Eft 1 LOCATED IN AN UtIOERGROU)(D VAULT 1 [ 3 02 NON-VAULTED 1 1 03 UNKNOWN ! <br /> IC. C ) 01 0OURLE WALLED (V) --_C2 S114GLE WALLED ( 1 03 LINED `_ -v— — ---_ _ - ------ - f -- — <br /> D. t CAPBOH STEEL ( 1 02 STAINLESS STEEL i 1 03 F16ERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> ( 3 OE ALUMINUM 1 1 07 STEEL CLAD ( 108 BRONZE f 1 09 COMPOSITE ( 3 10 NON-METALLIC <br /> [ 1 12 UIIKNOutI ( I 13 OTHER: <br /> FISC04-070185 i PAGE 1 <br />