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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> fOl NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED 09 DELETE FROM FILE (NO FEE) <br /> 2 CONDITIONAL PERMIT 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> � OPINE <br /> NAME(COPPOPATION,INDXVI,PUAL OR PUBLU AGENCYJ PUBLIC AGENCY ONLY <br /> r 0-5Y-01 FED 02 STATE 03 LOCAL <br /> CITY STATE <br /> STPEE A- <br /> ro <br /> II FACILITY <br /> FACIL.;TY NAME <br /> STREET ADDRESS v NEAREST CROSS STREET <br /> COU NTY ZIP <br /> ),C�,,f�kro 9 T-25-3,31 <br /> MAIL A SS CITY I STr ZIP <br /> PHONE W/AREA CODE TYPE�OFBUSINESS <br /> BU S <br /> I GASOLINE STATION (/t) 02 OTHER <br /> A SECTION <br /> TOWNSHIP <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY E <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> /AREA CODE S: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W <br /> F� .. <br /> COMPLETE THE FOLLOWING ON 4 SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. Od-01 TANK 04 OTHER CONTAINER NUMBER <br /> YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> B. MANUFACTURER (IF APPROPRIATE)- <br /> 0. CONTAINER CAPACITY: GALLONS UNKNOWN E. DOES THE CONTAINER STORE: 01 WASTE (Nd-102 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 01 UNLEADED 02 REGULAR 03 PREMIUM 06'04 DIESEL 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM 00-UNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 06 02 NON-VAULTED ( ) 03 UNKNOWNc. ol DOUBLE WALLED DeT 02 SINGLE WALLED 03 LINED <br /> D. 0%Qd 01 CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> ) 06 ALUMINUM 07 STEEL CLAD 08 BRONZE 09 COMPOSITE 10 NON-METALLIC <br /> 12 UNKNOWN 13 OTHER* <br /> PAGE I <br /> � *sc04-070185 <br /> ^ <br /> - <br />