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V <br /> STATE ID HUNGER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 PERMIT l 1 OS RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 01-DELETE FROM FILE (NO FEE <br /> 1 02 COt1DITI0NAl PEAHIT ( 106 AMENDED PERMIT 1 1 00 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> N,Y.t15,OPP(RATION.INCIVIOUAI 104 PUO�L,I^C AGENCY) PUBLIC AGENCY ONLY <br /> 1 Ol FEO 1 1 02 STATE_ 1 1 03 LOCAL <br /> TTAECT AC'19Ei2CITY SMTE 2 P <br /> II FACILITY <br /> ,PACIL IT AME DEALER/f OPEMEN'SUPERVISOP <br /> oL -- <br /> STPCET AODIESS NEAR ST CROSS STPEET <br /> _a7D_7ca/yasWor arl <br /> IC:TY S-i-oc-k i eoUNTr I <br /> MAILING ADOPESS (.J Y\_ CITY STATE <br /> r � Q t U �53a b <br /> PHONE W•A CAq.qCO E TYPE Of 5 <br /> 3-09 1 1 O1 GASOLINE STATIDN f 1 02 OTHER <br /> NUYEER Cf CONTAINERS <br /> PUPAL AREAS ONLY TOWNSNII 77]�� SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME1LAST NAME FIPSTI ANO PM <br /> W/APEA CODE NIONTS: NAMC(LAST NAME FIOST1 ND PHONE W/APEA CODE <br /> Y - - _ r 3 " 611 --- _ <br /> COMPLETE THE FOLLOWING ON A SEPARAtt FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TANK ( 1 02 OTHER_ _ . CONTAINER NUMBER <br /> B. MANUFACTUP.ER (IF APPROPRIATE): YEAR MFG' C. YEAR INSTALLED /??S'(J 1 UNKNOWN <br /> D. CONTAINER CAPACITY: `O�OVO GALLONS 1 1 LWHOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WAST OIL ? 1 TES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> 1 1 01 UNLEADED 1 1 02 REGULAR ( i 03 PREMIUM ) 04 DI SEL 1 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> fA. 71!ICF Nf SS OF PRIMARY CONTAINMENT: 1 1 GAUGEINCHES I I CM 1 1 UNKNOWN <br /> 18. f 1 01 VAULT EO 1-LOCATED IN All UNOERGPOU110 VAULT) Y v 02 NON-VAULTED 1 1 03 UNKNOWN - <br /> C. 1 1 01 DOUBLE WILLED X 02 SINGLE WALLED 1 1 03 LINED <br /> �0. I ARBON STEEL I 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD 11 OB BRONZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 UNKNOWN 1 1 13 OTHER: <br /> H5C04-07.^185 - PAGE 1 <br />