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REPRODUCED AT (,!Ajik<11 <br /> V4.NT EXPENSE ' <br /> STATE ID NUMBER <br /> APPLICATION ,FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t l <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> L("_(COPvORATION,INDIVID AL OR FUEL C AGENCY) LIC AGENCY ONLY <br /> "MO f VQ 1+-r v D4 l I O1 FED ( ) 02 STATE ( ) 03 LOCAL <br /> 0- 1 :BEET AC^KESS--• ( /� CITY STATE ZIP <br /> FACILITY <br /> CILITr N4.-,E DEALER/FOPEMEN/SUPERVISOR <br /> FEET AC^'ESS NEAREST CROSS STREET <br /> 'i COUNTY ZIP <br /> ILING ACOPESS CITY STATE ZIP <br /> ONE WAvEA COLE TlPE OF BUSINESS <br /> t 1 <br /> 01 GASOLINE STATION ( ) 02 OTHER <br /> :'BER CF CONTAINE:S PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> I 24 HOUR EMERGENCY CONTACT PERSON <br /> YS: NArE( LAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: ME( ST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPA FORMAVJ EACH CONTAINER <br /> DESCRIPTION -At ro <br /> 33 2 <br /> t, P' Y 01 TANK ( 1 02 OTHER: AAJ CONTAINER NUMBER <br /> MANUFACTURER (IF APPROPRIATE): wy YEAR MFG: TCYEAR INSTALLED ) UNKNOWN <br /> CONTAINER CAPACITY:a GALLONS ( l UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( ,,�,02 PRODUCT <br /> DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPR PRIATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> CONTAINER CONSTRUCTION <br /> THICY.NESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM ( UNKNOWN <br /> ( 1 01 Vv ULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED t ) 03 UNKNOWN <br /> t ) <br /> 01 DOUBLE WALLED tl.,.) 02 SINGLE WALLED ( ) 03 LINED <br /> 0.1 CARBON STEEL ( ) 02 STAINLESS STEEL- ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE t ) 05 CONCRETE <br /> ( )' 06 ALUMINUM t ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UI;KNOWN ( 1 13 OTHER: <br /> :04-0.01&5 PAGE 1 <br />