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- STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT ( } 05 RENEWED PERMIT ( ) 07 TANK CLOSET! --` ( } 09 DELETE FVM FILE (NO FEE) <br /> 102 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I 0 I-I N E R � <br /> NAr!(COPPQRATION,INDIvIDUAL OR FUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Ol FED { } 02 STATE ( ) 03 LOCAL— <br /> STeKESS - — - � STATR <br /> II FACILITY <br /> FACILITY NAME DEA /F REMEN/SUPERVISOP <br /> ejo <br /> STFEET ADL."fssr , NEAPEST CR SS STREET <br /> Lj I)o rn e <br /> CITY COUNTY — ZIP — <br />)fit MAIL IN AL DP ESS CITY STATE ZTP � <br /> f -SOL �(} <br /> PH DK ' WRAC€A CODE TYPE OF BUSINESS <br /> ( 01 GASOLINE STATION ( 1 02 OTHER <br /> NUNBEP OF CDNTA7NEcS PUPAL AREAS ONLY TOWNSHIP PANGE SECTION <br /> TIT 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: <br /> ME(LAST tAME FIRST) AND PHON . W/AREA CODE NIGHTS: NAME(LAST ME FIRST) AND PHONE, W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br />=4 <br /> A. TAIIK ( } 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED )qg S( i UNKNOWN <br /> D. CONTAINER CAPACITY: �Q (? GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( i 01 WASTE ( 02 PRODUCT - <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? I s 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOXIES): <br /> ( 1 01 UNLEADED ) 02 REGULAR ( } 03 PREMIUM ( 1 04 OIB'5'E"C ) 05 WASTE OIL t ) 06 OTHER -- <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ! GAUGE 1 1 INCHES ( 1 CM ( 1 UNKNOWN <br /> B. f 1 91 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ON-VAULTED f ) 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WILLED ( 02 SINGLE WALLED i 1 .03 LINED <br /> 1 01 CA.R80f4 STEEL ( }} 02 STAINLESS STEEL ( ISERGLASS ( 104 POLYVINYL CHLORIDE ( i 05 CONCRETE <br /> D. <br /> ( 1 06 ALUMINUM ( 1 07 STEEL CLAD ( 1B �ROtQE� ( 1 09 COMP05ITE ( 110 NON-METALLIC <br /> I 1 12 UNKNOWN i 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />