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Y �.r STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STQRA6E,,JANK <br /> 1}1 01 NEN PERMIT Of 00011410 1 1.47.TAW CASCO It, I '$9 DELETE, FROM FILE (NO FEE <br /> 1 1 02 CONDITIONAL PERMIT 1 1 N AMENDED PERMIT 1 1 OS MINOR CHANGE IID SURCHARGE$ <br /> I OWNER <br /> N4M9ICORRORATION,INDIV10U4t 01 OUStl1C AGENCY) - I ' t,.-�• PUBLIC AGENCY ONLY <br /> � ) y N ! 1 1 Ol FED 1 1 02 STATE l 1 OS LOCAL <br /> STREET AOORCSi CITY - STATE IIF. <br /> II FACILITY <br /> FACILITY NAME r O[Atel"oREM[N'fUR[RVISOR � `'4 <br /> A-L PIT fS (A�P-r 4�iw. e2 ! l Uc VAtm <br /> STREET A00REsf NEAREST COOS$ ;T_iEET <br /> / a S', /q%0002T _ 8 3 <br /> CITY S�0 GkYU� COUNTY S T ZIP<7 <br /> P<7 `-� 64 <br /> MAILINO ADDRESS I /^� - CITY J\ STATE zip J �O <br /> Z S. P"C-/ /2 U R-T S�6C- cl�- <br /> RxoN[ uIAR[A Coop! �j TIRE OF I 01 GASOLINE STATION 1 1 02 OTHER <br /> MJY.G[! CF CONTAINERS PUPAL AREAS ONLY TONNSN2► RANG[ SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> r <br /> DAYS: NA �f�N�� TP ��C N�� OAC Mlo" N� PASS NAME fIE2TNONE 4eAlEA CODE <br /> /.v/ /V� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> A. �\) 01 TANA< I 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER IIF APPROPRIATE)! i,Ji 12:, YEAR MFG: C. YEAR INSTALLED �'� 7`/1 I U J04N <br /> 0. CONTAINER CAPACITY: � ..) _i :? GALLONS l 1 UNILNONII E. GOES THE CONTAINER STORE: 1 1 01 WASTE l 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 1 1 01 YES 1 1 02 NO If YES CHECK APPROPRIATE BOX(ESI: <br /> 1 101 UUJLEAOEO (X\1 02 REGULAR I 1 OS PREMIUM 1 1 04 DIESEL l 1 05 WASTE OIL 1 1 06 OTHER__ <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE 1 I INCHES 1 1_CM_'(),/A UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN Atl UNDERGROUIID VAULT) 1 1 02 NON-VAULTED 1 OS UNKNOWN <br /> IC. 1 1 01 DOUBLE WILLED 0 02 SINGLE WALLED 1 ) OS LINED <br /> D. 1 1 01 CARBON STEEL 1 102 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 OS CONCRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD 1 1 00 BRONZE 1 1 09 COMPOSITE- 1 1 10 NON-METALLIC -— <br /> Ixl 12 UNKNOWII ( 1 13 OTHER: — -- <br /> nSC04-0;0385 PAGE 1 <br /> low <br />