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APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STATE ID NUMBER <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT <br /> 1 1 E TANK <br /> 02 CONDITIONAL PERMIT ( ) Ob AMENDED PERMIT 00 07 TAM( CLOSED <br /> �>f8 MINOR CHANGE (NO SURCHAR 9 DELETE FROM FILE (no FEE) <br /> I OvlNER <br /> NAME(COPPORATION. OIVIOVA <br /> JR PUBLIC AGENCY) <br /> QY� 1Q PUBLIC AGENCY ONLY <br /> STREET ADDRESS /•LC ( ) 01 FED ( ) 02 STATE <br /> O h'1'03 LOCAL <br /> G CITY <br /> STATS I ZIP <br /> II FACILITY C�eJL 9j <br /> FACIL TY NAME l <br /> JS DEALER/FOREM11A�N''/SUP.EP{R�V/j SOP <br /> STREET ADDRESS ` W�j /l l <br /> NEAREST CpOSS STREET o e rtli s o N <br /> CITY S 1� 94 <br /> COUNT <br /> PA J a a ZIP _ <br /> MAILING ADDRESS � � L�S <br /> .2 G CITY / J <br /> / an� ST ^ ZIP <br /> PHONE W/AREA CODE CGl /`" )CLI <br /> 2/`) �_ �� TYPE OF BUSINESS <br /> NUMBER vOF CONTAINERS 3 ( ) 01 GASOLINE STATION (S(Y02 OTHER Grp. Ycuu-c�, <br /> RURAL AREAS ONLY : TOWNSHIP <br /> RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/gREA CODE <br /> `7/$ a NIGH NAME(l ST NAME FIRST) AND PHONE W/AREA CODE <br /> � — � �(s e�^ aid/ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. fad"01 TAEE <br /> THER: CONTAINER NUMBER Op <br /> B. MANUFACTUOPRIATE): <br /> YEAR MFG: C. YEAR INSTALLED �.c <br /> ip/ f > UfA(NOWN <br /> O. CONTAINER CAPACITY: /07000) GALLONS ( ) UNKNOWN E. ODES THE CONTAINER STORE: ( ) 01 WASTE <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (ICY 02 PRODUCT <br /> ( 7 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL 0( )EIS WASTE 2OIL (I) o6OTHER <br /> APPROPRIATE BOKf ESI: <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: <br /> ( 1 GAUGE ( 1 INCHES f ICM (kr UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (11l 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C• ( ) 01 DOUBLE WALLED (�d 02 SINGLE WALLED ( ) 03 LINED <br /> D. 1 ) 01 CARBON STEEL f ) 02 STAINLESS STEEL f ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) OS CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE 1 ) 10 NON-METALLIC <br /> (7Q 12 UNKNOWN ( ) 13 OTHER: <br /> NSC04-070185 <br /> PAGE 1 <br />