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*TATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 01 NEN PERMIT ( 1 05 RENEWED PERMIT ( 1 07 TAN( CLOSED ( ) 09 DELETE FROM FILE IND FEE) <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( 1 04 MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> MC(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 1 01 FED 1 ! 02 STATE f ) 03 LOCAL <br /> POET ADDRESS CITY STATC ZIP <br /> FACILITY <br /> CIL TY NAME L../ / DEALER/FOREMEN/SUPERVIS <br /> L 01, `L Fr-e 4 rn c Ke_aA se,r\ <br /> PEETADD'W_ ^ NEAREST CROSS STRECT <br /> O M YV OL rn- 0 1 S <br /> TY COUNTY <br /> ZIP <br /> -} a � � �/yc_�Ly� Spy -a <br /> (LINO Ab (A ; CITY. 4,,c_` vl`� STATE ZNJ o9 <br /> N`�pl._ L a <br /> ONE u/A e• coneF BUSINESS <br /> S 7 J �� T`v; 001 GASOLINE STATION (X1 02 OTHER <br /> .BCR OI ,CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> I 24 (HOUR EMERGENCY CONTACT PERSON <br /> YS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> DESCRIPTION <br /> 01 TAN( ( ) 02 OTHER: CONTAINER NUMBER I it <br /> MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED f 1 UNKNOWN �I <br /> CONTAINER CAPACITY: 16obO GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE A) 02 PRODUCT <br /> DOES THE CONTAINER TORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 1 <br /> 01 UNLEADED 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL 1 1 05 WASTE OIL f ) 06 OTHER <br /> CONTAINER CONSTRUCTION <br /> THICKNESS OF PRI ART CONTAINMENT: ( ) GAUGE ( l INCHES ( I CM f I UNKNOWN <br /> 1 1 <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) A02 NON-VAULTED ( ) 03 UNKNOWN <br /> 1 1 <br /> 01 DOUBLE WALLED 02 SINGLE WALLED ( ! 03 LINED <br /> 1 ) <br /> 01 CARBON STEEL f 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM l l 07 STEEL CLAD ( 1 06 BRONZE f ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> l 112 UNKNOWN [ 113 OTHER: <br />:04-070185 PAGE 1 <br /> Co co <br />