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a • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK - <br /> ( 1 <br /> 01 NEW PERMIT l 1 05 RENEWED PERMIT C 1 07 TANK CLOSED l 1 09 DELETE FROM FILE (NO FEE) <br /> 1 ) 02 COIIOITIONAL PERMIT 1 1 06 AMENDED PERMIT I ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER _ ALOCAL NAME(COPP ATION.IND IVIDUAL OR PUBLIC AGENCY)s. PUBLIC AGENCY ONLY <br /> y�/{ �Q ( 1O1 FEO 1 l 02 STATE 1 ) '0STREET A On WS <br /> II FACILITY1^+^�/ YYVV <br /> FCITy NAME� OEAIER/FC M NYSUPEPVI$ P — <br /> �b�,..�A '�f SSNEAREST C OSS STREET <br /> COUNTY <br />=y9 <br /> MAI IIMQ?L`DRESS ICI <br /> ITY STAT! 2IP <br /> PMON! <br /> _411 CAA. <br /> CODE TYPE OF BUSINESS �` <br /> Ol GASOLINE STATION 1 1 02 OTHER 6eoy-lI <br /> NUMBER CF CONTA jN�ERS RURAL AREAS ONLY : TOWNSHIP PANG! SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> ME FIRST) AND PHO ^AREA COO! <br /> NIGHTS: NAM!(IPS; N M FIRST) AN0 PHONE W/6g6l <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAwINEERRR <br /> IV DESCRIPTION -_. -- - <br /> sic A. lel O1 TANK f ) 02 OTHER: CONTAINER NUMBER <br /> B. M-ANNIUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED_ f 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS I ) UNKNOWN E. DOES THE CONTAINER STORE: (>() 01 WASTE t ) 02 PRODUCT <br /> F. DOES THE CONTAINIER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? f ) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BO%IES): <br /> l 1 01 UNLEADED l 1 02 REGULAR 1 1 03 PREMIUM l 104 DIE EL ) 05 WASTE OIL f ) 06 OTHER__ <br /> V CONTAINER CONSTRUCTION <br /> A. <br /> THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE f l INCHES ( ) CM ( ) UNKNOWN _ <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. C 1 01 DOUBLE WALLED f 1 02 SINGLE WALLED ( 1 03 LINED _--_ <br /> D. t 1 01 CARBON STEEL f ) 02 STAINILESS STEEL ( i 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM 1 ) 07 STEEL CLAD ( 1 08 BRONZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />