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By OSFM Amount  FORMTEXT       Date  FORMTEXT       Check #  FORMTEXT      Action by MDEP  FORMCHECKBOX Complete  FORMCHECKBOX Incomplete Action By/Date:  FORMTEXT      Action by OSFM:  FORMCHECKBOX Approved  FORMCHECKBOX Do Not Issue Action By/Date:  FORMTEXT       Application for Permit by Rule & Certification of Compliance for Aboveground Storage of Diesel Fuel On a Significant Sand and Gravel Aquifer for Aggregate Mining Operations Office of the State Fire Marshal fb88 Department of fb88 Department of Public Safety Environmental Protection 52 State House Station 17 State House Station Augusta, fb88 04333-0052 Augusta, fb88 04333-0017 207-626-3880 207 287-7688 Name of Facility:  FORMTEXT      Physical Address of Facility:  FORMTEXT      Latitude (decimal)  FORMTEXT      Longitude (decimal)  FORMTEXT      Tax Map Number:  FORMTEXT      Tax Map Lot Number:  FORMTEXT      City/Town:  FORMTEXT      Zip Code  FORMTEXT      County  FORMTEXT      Contact Person:  FORMTEXT      Telephone:  FORMTEXT      Email or other:  FORMTEXT      Tank Listing:  FORMCHECKBOX UL 142 with Secondary Containment  FORMCHECKBOX UL 2080Number of Tanks and Chambers: Volume (gal) Product  FORMCHECKBOX Tank #1 One Chamber Tank  FORMTEXT        FORMTEXT        FORMCHECKBOX Tank #2 One Chamber Tank  FORMTEXT        FORMTEXT       or  FORMCHECKBOX Tank #1 Two Chamber Tank Chamber 1  FORMTEXT        FORMTEXT       Chamber 2  FORMTEXT        FORMTEXT       Total Capacity of all Tanks and Chambers  FORMTEXT       Total Capacity of all Tanks and Chambers MUST NOT Exceed 1,100 gal. 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