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STATE ID NUMBER <br /> -- APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 0I NEW PERMIT ( ) 05 RENEWED PERMIT ! 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT S ) 06 MINOR CHANGE (NO SURCHARGEI <br /> I 0W1NER <br /> NeY:tCpR4-PA' . YNDIVIDUIA OR P B IC AGENCY) PUBLIC AGENCY ONLY A <br /> OI FED I 1 02 STATE ( 1 03 LOCAL <br /> STRrE7 CIT STATE ZIP <br /> II FACILITY <br /> FACILITY NA:1E DEALER/FOPEMEN,SUPERVISpR <br /> STREET <CL''E55 NEAPEST CROSS STPEET <br /> `t:TY-,rti <br /> i7 ' — NTY ZIP <br /> MAItING A DRESS CITY STATE TIP <br /> -- � ( ►-� c <br /> f>MO2; <br /> W.AR A CIODE TYPE' CF BUSINESS '} <br /> + C) t 1 01 GASOLINE STATION f 02 OTHER <br /> ,UMbEP CF C�OONTAINER'S PUPAL AREAS ONLY ; TnW,WShIP '.'-- PANGE SECTION <br /> I.II 26 HOUR EMERGENCY CONTACT PERSON <br />` � Y MEiLq$7 A+) IPS AND PN EA CODE J� :TIG.1HT;'. MtIAS�NAME PIPST) AND PHONE WrAPEA Gc_ -- <br /> ,Ii��d\, -{lnTyl�^_ _- _. _Jynn�""�"��•.. _�Gs� �'(�`� ���__��a2. <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( ) 01 TA)(K f 1 02 OTHER: - CONTAINER NUMBER -�- <br /> 8. MANUFACTURER (IF APPROPRIATE): a YEAR MFG: I C. YEAR INSTALLED 06 UNKNOWNV <br /> O. CONTAINER CAPACITY= GALLONS t 1 (JNKNOWN E. DOES THE CONTAINER STORE: I 1 01 WASTE 2 PRODUCT <br /> F. 00 S THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ' 1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXtES): <br /> 'D f 1 Ut'LEADED ( 1 02 REGULAR f 1 03 PREMIUM f 1 04 DIESEL ( ) 05 WASTE OIL I ) 06 OTHER <br /> lam° . - --- — - <br /> V CCNTAINFR CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( I INCHES ( I CM ( ) UNKNOWN <br /> B. f ) 01VAULTED (LOCATED IN AN UNDERGROUND VAULT) (- )— NOM-VAULTED I ) 03 UNKNOWN <br /> SC. ( 1 01 DOUBLE W�LLE0 ,62 SINGLE WALLED f 1 03 LINED <br /> �D, t 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE A' <br /> ( ) ,06 ALUMINUM ( ) 07 STEEL CLAD C } 08 BRONZE ( ! 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( l 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br />