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W' <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED l ) 09 DELETE' FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 06 MINOR CHANGE (NO SURCHARGE) <br /> T OWNER <br /> NAMS(COPPORATIOr.INCIVIDUAL 0 FUSLIC AGENCY) UBLIC AGENCY ONLY — --- <br /> C p ) 01 FED ( ) 02 STATE ( 11 03 LOCAL) <br /> STCEET a.0^RESS S �J � CITY STATE Z+r�/ DD 71 <br /> II FACILITY <br /> FACILITY NAME ALER/ OPEMENISUPERVISOP <br /> STREET ACD'ES,S NEAPEST C OSS STREET <br /> CITY COVNTY ZIP <br /> STA E ZIP 6 <br /> l;f! M4IlIN ADOPESS CITY / - <br /> �. ` <br /> PHONE W%AVEA CODE TYPE CF BUSINESS <br /> 3 ( O1 ASOL,INE STATION ( 1 02 OTHER <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAP,,EfLAST AME FIRST) AND PHONE W/APER CODE NIGHTS: NAME(LA T NAME FIRST) AND PHONE W/AREA CODE <br /> AT <br /> IV DESCRIPTION <br /> �CONTAINERBER 3 <br /> •: A. (X11 TANK ( 1 02 OTHER: <br /> B. MANUFACTURER (IF APPROPRIATE '� YEAR MFG: , C. YEAR INSTALLED— ( 1 UNKNOWN <br /> D_CONTAINER CAPACITY. ALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (K 02 PRODUCT —-- <br /> F- DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 0 l 1 02 NO IF YES CHECK APPROPRIATE BOXIEST <br /> -1 -) 01 U11LEADED ( ) 02 REGULAR (�EMIUM ( -1 04 DIESEL l 1 05 WASTE OIL -1 1 06 OTHER__- _- <br /> V CONTAINER CONSTRUCTION <br /> A. THICY,NESS OF PP.IMARY CONTAINMENT: 14_!�) GAUGE ( ) INCHES ( 1 CM_( 1 UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNOERGROUNO VAULT) '(< 02 NON-VAULTED ( 1 03 UNKNOWN <br /> ,C. ( O1—0- <br /> OUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 3 FI RGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ! 0 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNUWN ( 1 13 OTHER: <br /> PAGE 1 <br /> HSC04-0 0185 <br />