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• • <br /> STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> \^j. !NEN PERMIT ( 1 05 RENEWED PERMIT t 1 07 TANK CLOSED ( 1 09 OELETC FROM FILE (NO FEE)- <br /> _ _1 02_COtIDITIONAL PERMIT _l 1 06 AMENDED PERMIT 1 1 OA MINOR CHANGE (NO SURCHARGE <br /> I OWNER _-- <br /> HAMEIC PPORATIOH.INOIVIOURL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> RAI- r--0. <br /> S t 1 Ol FED t 1 02 STATE ( 1 03 LOCAL <br /> fTt[!1 ACSf l �- CITYSTATE IIP <br /> s� <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPERVISOP <br /> ( r a <br /> BTR! A CESS -- NEAPEST ROSS STREET <br /> West' ll <br /> CITY C ' COUNTY ZIP <br /> —t�cc�__ <br /> MAILING AOOPESS CITY ZIP <br /> STATE 'a <br /> PHONE W%ACEA CODE TYPE OF BUSINESS <br /> l 1 01 GASOLINE STATION ( 1 02 OTHER <br /> Nur <br /> BER GF ONTAINlPS ... PUPAL APEAS ONLY TOWNSHIP PANGE SlCTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS' NAME(LAST NAME PIP TI AND PHONE W/AREA CODE NIGHTS: HAME(LAST NAME FIRST) ANO PHONE W,*AREA CODE <br /> �� - - C..Vq <br /> 46a- _7o - - <br /> COMPLETE TH FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> y A. t 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE I: YEAR MFG: C. YEAR INSTALLED I ) UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLON E. GOES TME CONTAINER STORE:_) r WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? �AEL� <br /> - YES ( 1 02 NO IF YES CHECK APPROPRIATE BO%IESI: <br /> ( 1 01 UtJLEAOEO ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 OIEASTE OIL I 1 06 OTHER___ <br /> V CONTAINER CONSTRUCTION <br /> A. THICY.NESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES ( 1 CM l ) UNKNOWN <br /> 8. ( 1 01 VAULTED I LOCATED IN AN Ut,'OERGROUt10 VAULT NON-VAULTEO l 1 03 UNKNOWN <br /> ,C. ( 1 01 DOUBLE WILLED SINGLE WALLED 1 1 03 LINEO <br /> 0. 1 CARBON STEEL t 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 OS CONCRETE <br /> l 1Y06 ALUMINUM 1 1 07 STEEL CLAD 1 1 OA BRONZE 1 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 12 UNKNOWN ( -1 13 OTHER--- - ------ -- ---- ------- -- - - -- - <br /> ►ISC04-04185 <br /> PAGE 1 <br />