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STATE ID NUMBER <br /> 1r APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> lei Ol NEW PERMIT l ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> f l 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) 00 MINOR CHANGE (No SURCHARGE) <br /> I OWNER <br /> NAME( OR(TIONND V <br /> .II Al OR PAGENCY( PUBLIC AGENCY ONLY <br /> �� �� UBLIC ( ) <br /> 01 FED 1 ) 02 STATE f ) 03 LOCAL <br /> Irn STRC ET ACORlSS / CIT ST E I <br /> Io2q Q—AMIE <br /> II FACILITY <br /> FAC AMC DEALER/FOPZMEN/SUPERVISOR <br /> STREET AODPlSS , NEAREST CROSS STREET <br /> oseCI115k� 1021 Com. lose- <br /> CITY <br /> TY �O L 107 COUNTY <br /> 15�` 1 �, Zi q r <br /> MASLiN� GUy a`+''�i•/`lr�Jll/VI-v CITY S �J L/FJ�S� <br /> ►MON! Wi Ae C DE TYPE OF BUSINESS <br /> I 1 01 GASOLINE STATION (Lt 02 OTHER <br /> ,NVMBER OR MNTAS NERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> NLMSER O�f NTAINEP.S <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS:�NAAMIV LAST NAME FIPST) AND IN7( AREA CODE NI"TS: NG;IIIAST N ME FIRST) AND PRONE W/AREA COD <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. t/01 TANK ( ) 02 OTHER: nAp' CONTAINER Nl1MBER (f.�/YI� � <br /> B. MANUFACTURER (IF APPROPMRIA�TE)° YEAR MFG r C. YEAR INSTALLED �� f 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 1GALLONS I ) UNKNOWN E. DOES THE CONTAINER STORE: 1 ) 01 WASTE 0+1'02 PRODUCT <br /> F. OQEj^E CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (V10,01 YES I ) 02 NO IF YES CHECK APPROPRIATE BOX(ES1= <br /> (K 01 UNLEADED ( ) 02 REGULAR 1 ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> ! '1 <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 ) GAUGE I�rIHCHES ( 1 CM f l UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Tyr 02 NON-VAULTED 1 1 03 UNKNOWN <br /> K� <br /> C. fO1 DOUBLE WALLED ' ( 1 02 SINGLE WALLED 1 ) 03 LINED <br /> D. (0'101 CARBON STEEL [ ) 02 STAINLESS STEEL X03 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM ( ) 07 STEEL CLAD [ 1 08 BRONZE ( ) 09 COMPOSITE- f l 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-07,0185 PAGE 1 <br /> � 1 <br />