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t STATE 20 ER <br /> APPl.KATION FOR-. PIRM:ZT:...TO OPIERATENDERGROUN�_;STII� x�TANK <br /> - -, <br /> T" Ot IT " l ; 05 11 i ( 't-Q1�T 1;0 .; 4 k I SCL Tf.".fROM FILE (NOFEEL <br /> U't 02 tTtONAL PERMIT t ! Ot< G'0 Pf RMtT I '1 44 ftINOR:l*ANW tM0 1 <br /> I OWNER _ <br /> NwKEtCQR®pRATIONe %VIOUAI Nbt AGENCYe LIC AGENCY ONLY <br /> t t 01 FED t 1 02 STATE 1 ,1 03;LOCAL <br /> TTMLET-.AONRESgS CITY ' y sT Z%! q <br /> Y <br /> :11 FACILITY <br /> t <br /> FAC% TY "AMC1 OEAIER/FOPEMENK P RV%sOR � <br /> ? STREET�A 1 s NEAR T coosp STREET <br /> CiTr � COUNTY� � 2IP <br /> MAItIio`ADOPESS CITY <br /> PN0NE'N,'A69A CODE Tr Of ®USINESS- <br /> 1 01 GASOLINE STATION t 1 02 OTHER <br /> NUMBER OF CONTAINERS RVRAL AREAS ONLY T NSHIP TPANGE sECT%ON <br /> YII 24 HOUR EMERGENCY CONTACT PERSON <br /> 0A : NAMlt T N E RSTD AND PHONE W/AREA CODE N TSS HAMCCLAS NA E FIRSTI AND.,PHONE W✓AREA CODE <br /> :- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> tag A. i 1 01 TAW t 1 02 OTHER: CONTAINER NUMBER <br /> - 5. MANUFACTURER (IF APPROPRIATE12 _ _. YEAR MFG: C. YEAR INSTALLED _ -:, t_ 1 UNKNOWN <br /> D. CONTAINER CAPACITY: $ GALLONSt 1 UNKNOWNE. DOES THE CONTAINER STORE: ( 1 01 WASTE ( 1 :Q2 PRODUCT <br /> F. Q—S THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( D 01 YES t 1 02 NO IF YES CHECK APPROPRIATE 5OX(ES1: <br /> ( O1 U;tLEADEO ( -1 02 REGULAR t ) 03 PREMIUM t 1 04 DIESEL ( i OS WASTE OIL t 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKtIESS OF PRIMARY CONTAINMENT: 1 1 GAUGE t 1 INCHES ( 1 CM t D UNKNOWN — — <br /> B. t 1 01 VAULTED (LOCATED IN AN UNOERGROLNtO VAULT( 'tR) 02 NON-VAULTED 1. 1 03 UNKNOWN <br /> ,C. t '1 01_DOUBLE WALLED—t 02 SINGLE MALLEO t D-03 LINED <br /> D. ! 1 01 CARBON STEEL t 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE t ) OS CONCRETE <br /> ( 1 06 ALUMINUM t D OT STEEL CLAD t D 08 8ROtlZE 1 1 04 COMPOSITE ( D 10 NON-METALLIC <br /> t 1 12 LRtKNOWtt t 1 13 OTHER: <br /> — <br /> PAGE 1 <br /> I <br /> t1SC04-070185 <br /> j <br /> I <br />