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STATE 10 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND 5TORAGE TANK <br /> f 1 D1 NEW P€RMIT [ 1 05 RENEWED PERMIT ( ) 07 TANK CLOSEO <br /> l 1 09 DELETE' FROM FILE (NO FEE 1 <br /> i 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 OB MINOR CHANGE IND SURCHARGE) <br /> i OWNER <br /> MAME(CORPORATION,INqIVIDUAL OR fUBLIC ENCYI PUBLIC AGENCY ONLY <br /> T r r l I O1 fE0 1 ? 02 STATE ( .1 03 LOCAL <br /> STREET A09PES ITY <br /> Pte <br /> II FACILITY <br /> FACILITY N — / S r DEALER/FOPEMEN/SUPERVISOP <br /> vv <br /> _ ► NEAPEST CROSS STPEET <br /> STPEET RCL'TESS <br /> COUNTY ZIP - /C•r� <br /> CITY �f <br /> !� K• lt� � t�'ti'-ea� �!'1 Dai G ! /c> �" <br /> AV <br /> NG DPESS <br /> CITY �!� ST T <br /> MAILIZIPg sem.. <br /> _ ,a. 2 1.2 <br /> PHONE W,AVEA CODE TYPE OF BUSINESS C -7 5/'Z- <br /> 01 GASOLINE STATION (}rr k2 0THER (1 GI%�� �ti <br /> NUMBER CF C7NTAI EPS — RUPAL AREAS ONLY TOWNSHIP PANGE SECTION <br /> III 24 }TOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEaLA TAME FIPSTI All PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> /S <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION ------ <br /> :F A. { 1 01 TANK ( 1 02 OTHER: CONTAINER HUMBER <br /> IB. MANUFACTURER QIF APPRbPRIATEI: YEAR MFG: C. YEAR INSTALLED Q�1 UNKNOWN <br /> D. CONTAINER CAPACITY: G' GALLONS t 1 UNKN0=EDTHE CONTAINER STORE: 1 1 01 WASTE l 1 02 PRODUCT — <br /> �—�-- <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR 'WASTE; OIL ? I 1 O1 YES i 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> I 1 <br /> 01 LPILEAOED t 1 02 REGULAR ( 1 03 PREMIUM (/'1, 04 DIESEL- ( 1 05 WASTE OIL -I 1 06 OTHER <br /> V CONTAINER CONSTRUCTION --- ------- <br /> A. THICKNESS OF PRIMARY CONTAINMENT- 1 1 GAUGE ( 1 INCHES ( 1-CM ( I UNKNOWN -` <br /> 6. ! 1 01 VAULTED (LOCATED IN AN UNOE9GR0Ut10 VAULT) ( 1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. f 1 01 OOUBLE W1LLE0 (>1 02 SINGLE WALLED 1 1 03 LINED <br /> 0. (XI QI CARBON STEEL I 1 02 STAINLESS STEEL Q 1 03 FIBERGLASS I ) 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> 1 06 ALUMINUM I 1 07 STEEL CLAD t 1 06 BROttZE ! 1 09 COMPOSITE t 1 10 NON-METALLIC <br /> f 1 12 UTIKNOWII l I 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />