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STATE ID NUMBER <br /> APPLICATION .FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (kj--01 NEW PERMIT t 1 05 RENEWER PERMIT ( ) 07 TANK CLOSED <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> p(1BLIC AGENCY ONLY <br /> NAYE(COPpC N.INOIVIDUAL OR RUBL AGENCY) ( ) 01 FED ( 3 02 STATE [ 1 03 LOCAL <br /> r_lz <br /> CITY / STATL07- 1 <br /> ZIP <br /> STPEET AD <br /> II FACILITY <br /> FACILITY Y,E / ol DEALER/FOP MEN/5VPERVI54R <br /> NEAPEST CROSS STREET <br /> STREET AOVniSs <br /> cauNTY ZIP <br /> CITY <br /> 77 <br /> MAILING A € 5 Y <br /> CITSTA ZIP <br /> PHONE W+ATEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION ( 'I_02 OTHER <br /> NUMBER CF CONTAINERS <br /> PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS,a�NAr,EILAST NAME FIRST) AND PHONE W/AREA CODE NSGHTS' NAME(LAST NA E FIRST)—AND PHONE W/APEA COOS <br /> L ,� - "gD 2jff<D G <br /> �/ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( Q- --f4tiK [ ) 02 OTHER: CONTAINER NUMBER - <br /> B. MANUFACTURER (IF APPROPRIATE) � fC.r�s'/yam YEAR MFG:,e5 C. YEAR INSTALLED ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY . GALLONS [ ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? YfS [ ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM � 1�-f04"DIESEL S ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE [ ) INCHES ( ) CM (LY UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UtOERGROUNO VAULT) 1_ _-NON-VAULTED ( ) 03 UNKNOWN <br /> 1C. ( ) 01 DOUBLE WALLED ( 'I�SINGLE WALLED ( ) 03 LINED <br /> D. ( ) Ol CARBON STEEL ( 1 02 STAINLESS STEEL f �_=.F36ERGLASS ( 1 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> { ) 06 ALUMINUM ( ) 07 STEEL CLAD ( l 08-BR61)LE I 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> SC04-00185 <br />