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STATE zoNUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> (>,Y 01 NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> 02 CONDITIONAL PERMIT 06 AMENOED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OPINEM0RATION,IN0Iy40UAL 0 01 FED 02 STATE 03 LOCAL <br /> � <br /> CY ONLY <br /> � <br /> I_Z�� STATE <br /> TI FACILITY � <br /> FACILIT�Y NAME <br /> �olr_ —A r ar <br /> NEAREAT CROSS ST T <br /> CITY kirC)yg <br /> Joa- <br /> CITY STA ZIP — <br /> STATION 11102 OTHER <br /> PHONE W/AREA CODE TYPE OF BUSINESS ION (?q 02 OTHER <br /> I GASOLINE STAT <br /> iT Y�P_100 I <br /> lEAS ONLY TOWN A _E SECTION <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> FIRST) AND PHONE W/AREA CODE <br /> /AREA CODE St NAME(LAST NAME <br /> FY NAME(,LAST NAME FIRST) AND PHONE W <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> CONTAINER NUMBER <br /> A. (*01 TANK 04 OTHER- <br /> B. MANUFACTURER (IF APPROPRIATE)* YEAR EMFGZC. YEAR IN:S�TALLED 00-tWNOWN <br /> GALLONS lLU;JWNO:WMjE�._l00ES THE CONTAINER STORE: 01 WASTE (>�*-02 PRODUCT <br /> 0. CONTAINER CAPACITY <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 00-01 YES 02 NO IF YES CHECK APPROPRIA <br /> J�,i 01 UNLEADED 02 REGULAR 03 PREMIUM 04 DIESEL 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM 0,4"UNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) t_)eO2 NON-VAULTED ( ) 03 UNKNOWN' <br /> c. ol DOUBLE WALLED (_Ncr 02 SINGLE WALLED 03 LINED <br /> 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> D. (Nd"01 C�ARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS ( ) <br /> I)l 5 LUM ST UM 08 BRONZE 09 COMPOSITE I ) 10 NON-METALLIC <br /> 06 ALUMINUM 07 STEEL CLAD <br /> NOWN <br /> ff( ) 12 UNKNOWN 13 OTHER: PAGE I <br /> � osc0*-070185 <br /> _ <br />