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� <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> (N�Y fOl NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> 2 CONDITIONAL PERMIT 06 AMENIJED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OPINE <br /> NAME(COPPORATION,INDIV DUAL OR PUBL AGENCY) ' PUBLIC AGENCY ONLY <br /> (��'Oi FED 02 STATE 03 LOCAL <br /> Koo- <br /> II FACILITY <br /> NEAPES� CROSS STREET <br /> COUN�� ZIP <br /> CITY <br /> L NL <br /> CITY IP <br /> PHONE W/APEA CODE ITYPE OF BUSINESS <br /> NUMBER OF CONTAINERS RURAL AREAS 0�,LY�: TOWNSHIP RA-NGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> /AREA CODE NIGHTS: NAME(LAST HE W/AREA CODE <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W NAME FIRST) AND RHO <br /> F� ... - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> CONT <br /> A. (>I-__0i TAW 04 OTHER: =AINER NUMBEER <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: __ C. tYEAR INSTALLED <br /> 0. CONTAINER CAPACITY: _-_)_A00 GALLONS L( ) UNKNOWN E. DOES THE CONTAINER STORE-. 01 WASTE (_-4-02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (>0-01 YES 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> j�-,1'01 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 ( 4-UNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (N"Z NON-VAULTED ( ) 03 UNKNOWN- <br /> C. 01 DOUBLE WALLED 01:r_02 SINGLE WALLED 03 LINED <br /> � osc04-070185 <br />