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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> t 102 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) —! <br /> I OWNER 1 <br /> NAMEE(COPPORATION.INOIVIDUAL OR FUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> �(iltNkg ET 1 01 FED ( D 02 STATE ( ) 03 LOCAL <br /> STREET AOORESS CITY STATE 12P <br /> --- EnIT� SE <br /> 456 7 <br /> fZi <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPEPVZSOP <br /> ST-0 P YK 2.KE' 4 <br /> STREET'AOO�ESS SS STPEET NEAREST CRO <br /> t�z® e <br /> C24Y ,, COUNTY 22P <br /> ZOD/- S.4AJ '7014Q—AJ 2v0 <br /> MAILING ADOPESS CITY STATE IIP <br /> . 0. .60>, Jc7 S� 2E ONT dh 1 1.15-33 <br /> PHONE W%ACEA CODE TYPE OF BUSINESS Co IN/444lEr <br /> 01 GASOLINE STATION (X) 02 OTHER 64TH (<4S6[/NE <br /> NUMBER OF CONTAINERS PUPAL AREAS ONLY TOWNSHIP PANGS SECTION <br /> e <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAY,E(LAST NAME FIPST) AND PHONE W/APER CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APER CODE <br /> 6,-12 ti_X6cK Ws­ 6S'1- 8�� c�vr��- 4/6 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. t�) 01 TANK t ).02 OTHER: CONTAINER NUMBER <br /> B. MAiZ ACTURER (IF APPROPRIATE): X areg ES YEAR MFG:;ya C. YEAR INSTALLED �Y�� t ) UNKNOWN <br /> D.,CONTAINER CAPACITY: l®J OD GALLONS t ) UNKNOWN JE. DOES THE CONTAINER STORE: ( 1 01 WASTE 00 02 PRODUCT <br /> F ',DOES THE CONTAINER TORE MOTOR VEHICLE FUEL OR WASTE OIL ? ()G 01 YES ( 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> I 1 01 UNLEADED ( ) 02 REGULAR ( D 03 PREMIUM ( 8 04 DIESEL ( ) 05 WASTE OIL t 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> c N <br /> A. THICKNESS OF PRIMARY CONTAINMENT: e3 7® ( ) GAUGE ( l INCHES ( ) CM t l UNKNOWN <br /> S. t 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Ski 02 NON-VAULTED ( ) 03 UNKNOWN <br /> �C.` 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED t D 03 LINED <br /> ID. 1 1 01 CARBON STEEL t ) 02 STAINLESS STEEL �C) 03 FIBERGLASS ( 1 04-POLYVINYL CHLORIDE ( ),'05 CONCRETE <br /> ffi t 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE t ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> j ..:,-I 3 12 UNKNOWN ( ) 13 OTHER: <br /> Sr-04-070185 PAGE 1 <br /> a'� <br />