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SPATE 11) NUM'3EG' <br /> • APPLICATION FOP PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( Cl NEW PRRi:IT ( ) 05 RENEWED FLRMIT ( ) 07 TA)8( CLOSED ( ) 09 DELE",.: FPOM FILE (NO FEE) 1 <br /> 02 CrND;TIbNAL PERMIT ( ) 06 AMia0FD PERMIT ( 1 OU MINOR CHANGE (NO SURCHARGE) <br /> I OdNFP. <br /> J.'.AME(CORPO(r<.-ICt ,• IV DUAL OR PUBLIC A °t:Cl') PUB-IC ASFOC( ONLY <br /> ' -6c ) 01 FED c l 02 sTr.Tv ( ) 03 LOCAL <br /> — — _ _ <br /> !STPEFT ADDRESS <br /> rc;IijTy ,- <br /> STATE ZIP <br /> lI FACILITY <br /> ;FACILITY I:AME J) DEALER/FOREMAN/S ERVI508 <br /> ;STFEt:T ADDRESS NEAREST CPO STREET <br /> (CITY COU TY <br /> 41 1ZIPln 3.3I <br /> r.sILING LDRESS CITY <br /> STATE Z'P <br /> D <br /> lFHOtt W/AREA COD-c TYPE OF BUSINESS <br /> I ) 01 GASOLINE STATION ( ) 02 OTHER <br /> iir•'1M.9ER OF CCNTA7t:EPS PUP AL AREAS ONLY ]TOWNSHIP RANGE SECTION - --� <br /> 11 -1 2'1 24 HOUR EMERGENCY CONTACT PERSON <br /> ::tiiS: N..ME(LAST NAME FI'ST) ND 11ONE W/AREA CODE ----it:IGHTS: NAME(LAST NAME FIRST) A PHONE WiAREA CODS --� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FOri•t FOR EACH CONTAINER <br /> iV DESCRIPTION <br /> Ok OTHER: CONTAINER NUMBER 2 <br /> t <br /> i <br /> 5. MAJAJFALTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED/`y� <br /> i <br /> D. CONTAINER CAPACITY: 'L GALLONS-( ) UNKN01,'N E. DOE5 THE CONTAINER STORE: ( ) 01 WASTE (X 02 PRODUCT <br /> F. DCLES THE CON.AINCR STORE MOTOR VEHICLE FUEL OR WASTE OIL ? YES ( ) 02 NO IF YES CHECK APPROPRI TE BOX(ES): <br /> r Ltti!EADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DI SEL ( ) 05 WASTE OIL A OG OTHER <br /> e — <br /> V CONTAINER CONSTRLICTION <br /> iA. THICKNESS OF PRIMARY CO JTAINNENT: GAUGE (X,_UjC)tES ( ) CM (-) NKNOWN <br /> I:. ( ) O1 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( )(02 ttCN-VAULTED ( ) 03 UNKNOWN <br /> IC_L l 01 DC)UE+LE );ALLED ( 0/_'-SINGLE-WALLED ( ) 03 LINED <br /> iD. ( ) 01 CARSC:: STEEL ( ) 0.^. STAIt:iEFS -rEEI ( FIBERGLASS ( ) 04 POLYVINYL CtLURIDE ( ) 05 C014(:RE1F: <br /> j ( ) OS ALL".11HUM ( ) 07 STEEL. CLA' i - BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> j ( ) 12 UNKNOWN ( ) 13 OTHEr: <br /> HS,-"-0701f5 PAGC 1 ! <br /> r <br />