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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (-Nf'O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEED <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I <br /> 0 d N E R <br /> NAME(C pORA7I0N,INDIVZD AL OR PURL AGENCY) PUBLL AGENCY ONLY <br /> 01 FED t ) 02 STATE [ l 03 LOCAL <br /> -� -- CZTYSTA E JIP <br /> $TRE ADDRESS _? <br /> II FACILITY <br /> �FACII Y NAME DEALER/FOREM.AN/SUPERVISOR <br /> STRE ADD�R SS _ NEAREST CROSS ST EE4 <br /> COUNT llqq � ZIP <br /> CITY �V <br /> CITY STAT ZIP _ <br /> MAIIZN AD R SS <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> r [�` ( ) O1 GASOLINE STATION ( 02 OTHER / IIS <br /> NUMBER OF CONTAINERS ! RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> F <br /> NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> _._ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ('�t'01 TANK ( ) 04 OTHER: CONTAINER NUMBER ` S-1- L <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLED Ly UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (- 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? Ol YES ( D 02 NO If YES CHECK APPROPRIATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 4 DIESEL ( ) 05 WASTE OIL ( D 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( D GAUGE ( ) INCHES ( ) CM (34-UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED 02 SINGLE WALLED ( D 03 LINED <br /> D. S 01 CARBON STEEL ( D 02 STAINLESS STEEL ( ) 03 FIBERGLASS t D 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( D 07 STEEL CLAD ( D 08 BRONZE ( D 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> - PAGE I <br /> HSC04-070185 <br />