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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> i <br /> 01 NEW PERMIT F ( 1 05 RENEWED PERMIT 7 1 07 TANK CLOSED - --t 109.OELETE FROM FILE [NO FEE I <br /> 2 COtIOITIONAL PERMIT -I-1 06 AMENDED PERMIT _ 1 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER - - --- - - <br /> )MAP-!(COPPORA`ION.INCIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Al e5 [ I 01 FED l 1 02 STATE 03 LOCAL <br /> STP€ET AC'lR€SSCITY STATE LIP <br /> II FACILITY <br /> 7ACILITY NAME DEALER/FOPEMENISVPEPVISOP <br /> 'E-rIG�LL}/�► /� I!'�G 7/ - _ /�� , taF •r e <br /> S7FEET :-Od'ESS NEAPEST CROSS STPEET <br /> CITY - COUNTY <br /> 1 I P �`4y i/✓` <br /> ' nsIIING AdDPESS CITY _ r STATE_ ZIP � <br /> PHON! WIACEA COVE TYPE OF BVSIN_SS Ca� <br /> �-os-z? I 1 01 GASOLINE STATION 1 02 OTHERI -- - i <br /> NUI'BEP Cf CONTAINERS PURAI AREAS ONLY : TOWNSHIP PANGE SEC7iON <br /> III 26 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAIIECLA.ST NAME FIPSTI ANO PHONE W/APIA CODE NIGHTS: NAMEILAST NAPE FIRST) AND PHONE W/APIA CODE <br /> eo d ZrJ '13 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TANK ( 1 02 OTHER: ya_,A CONTAINER NUMBER- 7 <br /> B. MAIfUFACTUP.ER ( IF APPROPRIATE )' — — YEAR MFG: - C. YEAR INSTALLED t-) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS t ) UNKNOWN E. DOES THE CONTAINER STORE: { 1 01 WASTE (Z 02 PRODUCT <br /> F. DOES THE CONTAIIIER STORE t10TOR VEHICLE FUEL OR WASTE OIL ? [ 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> 1 1 01 U:!LEAOED ( 1 02 REGULAR t 1 03 PREMIUM 1 1 04 DIESEL t 1 GS WASTE OIL 1X G6 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TPTCItNFSS OF PP.IMARY CONTAINMENT: ( T GAUGE X) INCHES l 1 CM I I UNKNOWN <br /> B. I 1 01 VAULTEII (LOCATED IN AN UIIOERGPOUHO VAULT I 1 1 02 NON-VAULTED 1 I 03 UNKNOWN 1.'o, <br /> IC. 1 0) DOUBLE WILLED (<l 02 SltIGLE WALLED f ,ei 03 LINED <br /> �p. ( 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINU 1 ).07 STEEL CLAD ( I GB BP1011ZE f 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> { 1 I 12 UNKNOWN l� 13 OTHER: <br /> _ PAGE 1 <br />