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STATE ID NUMBER <br /> J✓ <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK �— <br /> - -- <br /> ( 1 01 NEW PERMIT l 1 05 RENEWED PERHIT ( 107 TANK CLOSED ( ) 09 DELETE FRCM FILE (NO FEEI <br /> ( 1 02 CONDITIONAL PERMIT f 106 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER - - <br /> -- - -- -» —-_ - --- ---- <br /> LP(U,3)LO- <br /> --tCITYTATE <br /> C AGENCY ONLY <br /> NAY.EdCOPaORATION.INDIVIDU4L OR FUBLIC AGENCY) I FED f 1 02 STATE 1 03 LOCAL <br /> ZIP <br /> �SZ/T'i/'�'�— a <br /> II FACILITY <br /> DEALER/FOPEMEN/SUPEFVISOP <br /> FACILITY NAME <br /> L'`ESS ! `` _ <br /> NEAPEST CROSS STPEET <br /> STREET FC <br /> .y n fl M Ri��h Pt AGS - - _-_ _7 - - <br /> CITY Tf' f COUNTY Y ZIP �-� <br /> C� *_� <br /> S1 jo ► - - <br /> •.� �_� _-- CITY STATE ZIP G <br /> MAILING ADDPESS <br /> PHONE W,ACEA CODE [_ T)PE OF BUSINESS <br /> ��S�t� 8-Z 3 (X) 01 GASOLINE STATION ( 1-02 OTHER —_- <br /> NUt"BER CF CONTAINERS TRUPAL AREAS ONLY TOWNSHIP PANGE SECTION — — <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> [DAYS: NAMEILAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE - <br /> y <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION _ <br /> A. ( i Oi TAIIK t ) 02 OTHER.--- --- - -- ----- ----___� T- CONTAINER 18JMBER <br /> B. MANUFACTURER (IF APPROPRIATE ), T YEAR MFG C. YEAR INSTALLED �— (xl UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE' ( ' 03 WASTE l } 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? { 1 01 YES f ! 02 NO IF YES CHECK APPROPRIATE BOX(ES) <br /> f 1 <br /> 01 UNLEADED f 1 02 REGULAR ( } 03 PREMIUM ( } 04 DIESEL v,V) 05 WASTE OIL t 1 06 OTHER_ <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( I GAUGE ( I INCHES [ 1-CM ly UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNOERGROUNO VAULT) ( 102 NON-VAULTED f 03 UNKNOWN <br /> ]C. i 101 DOUBLE W' LLEO ( 102 SINGLE WALLET) ( 103 LINED <br /> D. 1 01 CARBON 5 ( 1 02 STAINLESS STEEL f 1 03 FI6ERGLASS ( M 04 POLYVINYL CHLORIDE ( ) DS CONCRETE <br /> r0 ALUMIIJUM ( ) 07 STEEL CLAD ( ) 06 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER - ------ - - -- _- _ �_-- _-- <br /> --- --- - -- PAGE 1 <br /> HSC04-0/0185 <br />