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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> J1e1 01 NEW PERMIT ( ) 05 RENEWED PERMIT 1 1 07 TANK CLOSED _— ( ) 09 OELETt FROM FILE (NO FEET <br /> 1 1 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> MAAr.!((COPP�ORATIION/.INDIVIDUAL OR FUIOLICMADENCYI G'C ,/nn <br /> Q\1ao PmPUBLIC AGENCY ONLY <br /> J& 1/ l ) 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> • STREET ACn1LE�o ��_ T - <br /> /6 CITY ) STATE ZIP <br /> II FACILITY <br /> ,FACILITY NAME DEALER/FOPEMEN/SUPEPVISOP <br /> s�o ccezo'✓ DPvT�P - G� -- i�/�/z2�y� /-i r_1 yA-X-0 <br /> S:REA4i�A?L*R SS / NEAPEST CROSS STREET / <br /> M A—i�nryo Ll e <br /> CITY 7/P0,01'' <br /> COUNTY_S * A vD�L+Ka 11 =IP9s!/V � <br /> „.:LINO �%0S �. M�6 Nal-1 DUTY STATE ZIP . <br /> -- ��A1u.✓ G�4 yS2 cTt <br /> PHONE WAelA CODETYPE CF SVS IN_SS P �" •� <br /> �+ <br /> 1 Ol GASOLINE STATION l 1 02 OTHER <br /> NVrpER CP CONTAINERS RURAL AREAS ONLY TOWNSHIP PANG! SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: Ar.E(LAST NAME FIRST) AND PHONE W/AREA CODE HIONTNAME(LAST NAME FIRSTI AND PHONE W/APER CODE <br /> �I,V iIARn �AQo<rt - B9 9dR 7/// <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> ffi A. 1 01 TANIK f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATEI: YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAIIIER CAPACITY: j}�d U_ GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE (- 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES 0692 NO .IF YES CHECK APPROPRIATE BO%(ES1: <br /> 1 1 01 UNLEADED 1 1 02 REGULAR l 1 03 PREMIUM L 1 1 05 013TIE OIL y J, OITHER - <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 ) GAUGE 1 1 INCHES 1 1 CM ( I UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) )P<102 NON-VAULTED 1 1 03 UNKNOWN _ <br /> 1C. 1 1 01 DOUBLE WILLED i 02 SINGLE WALLED 1 1 03 LINED <br /> D. 1� CARBON STEEL 1 02 STAINLESS STEEL ( 1 03 F16ERGLASS l 1 04 POLYVINYL CHLORIDE ( 1 OS CONCRETE <br /> 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 06 BRONZE 1 1 09 COMPOSITE l 1 10 NON-METALLIC <br /> 1 1 12 UNKNOW)) l 1 13 OTHER: <br /> NSC04-070185 --_— _--------- --- PAGE 1 <br />