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0 STATE ID NUMBER <br /> TANK <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE LETS FROM FILE (N0 FEE) <br /> t 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED <br /> f 1 02 NEW PERMIT PERMIT ( 1 06 AMENDED PERMIT ( ) OQ MINOR CHANGE (N SURCHARGE) <br /> CMI[ ------------- <br /> OWNER PU9LIC AGENCY ONLY <br /> ( ) O1 FED t ) 02 STATE [ ) 03 LOCAL <br /> NAME(COPPORATION INOIVIDU;, OR PUBLIC AGENCY) STATE YIP <br /> CITY <br /> STREET AOI7RESS <br /> II FACILITY <br /> DEALER/'f OREMEN/SURERVISOR <br /> FACILITY NAME <br /> NEAREST CROSS STREET <br /> STREET ACOPESS ZIP <br /> COUNTY <br /> CITY STATE ZIP <br /> CITY <br /> MAILING ADDPESS <br /> TYPE OF BUSINESS <br /> PHONE W'ACEA CODE ( ) O1 GASOLINE STATION ( ) 02 QTHER. <br /> SECTION <br /> - RANGE " <br /> PUPAL AREAS ONLY 7 TOWNSHIP <br /> NUMBER CF CONTAINERS <br /> III 24 HOUR EMERGENCY CONTACT PERSON NIGHTS: NAME(LAST NAME FIRST)^AND-PHONE /AREA CODE <br /> DAYS: NAME(LAST NAME IFIPSTI AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SE�'ARATE 'FORM FOR EACH CONTAINER _ -.-- <br /> COMPL -� <br /> IV DESCRIPTION <br /> CONTAINER NUMBER <br /> A. t ) 01 TANK t ) 02 OTHER: „� ( ) UNKNOWN <br /> YEAR MFG C. YEAR TNSTALLED <br /> B. MANUFACTURER (IF APPROPRIATE)' <br /> ' GALLONS l ) KNOWN E. DOES THE CONTAINER STORE! i ) 01 WASTE l ) 02 PRODUCT <br /> D. CONTAINER CAPACITYUN <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE Q4LOIESEL 0( )E 2QIS K APPROPRIATE BOXIES)= <br /> 05 WASTE OIL f ) 0$ THER <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM <br /> U CONTAINER CONSTRUCTION <br /> GAUGE INCHES CM UNKNOWN <br /> A. THICKNESS OF PRIMARY CONTAINMENT: <br /> ( ) ( ) i ) l ) <br /> B. f ) ql VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED t ) 03 UNKNOWN <br /> INED <br /> }C, ( ) O1 DOUBLE WALLED f ) 02 SINGLE WALLEDi ) )0LFIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> O1 CARBON STEEL ( 3 02 STAINLESS STEEL i 03 <br /> f lq NON"METALLI <br /> ) 06 ALUMINUM ( ) 07 STEEL CLAD t 1 08 BR <br /> ONZS ( 1 09 COMPOSITE ( ] - <br /> ( ) 12 UNKNOWN l 1 13 OTHER -- -- �- PAGE 1 <br /> H5C04-074185 <br />