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STATE ID NUMBER <br /> APPLICATION ,FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> IX) 01 NEW PERMIT l 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> l 1 02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT 1 1 OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPCRaTION,INDIVIDUAL O? FueIIC AGENCY) =�k PUBLIC AGENCY ONLY <br /> �� S.�d ,-rO-�Q 1 1 Ol FED 1 l 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE IIP <br /> �Ct I f � r✓t ,2t eco a eras. C/a ci 21.�� <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SVRERVIS R <br /> 4 T 3 <br /> STREET AOC?ESS NEAREST CROSS STREET <br /> o-Q GQ" , <br /> clTy COUN� IIP <br /> S 0 9( 20 <br /> MAILING ADDRESS CITY STATE ZIP <br /> f� U.. 3 I L) !�4 9f7,0 <br /> 'NONE W/AFEA CODE TYPE OF BUSINESS <br /> 20-r ,/P- ('C0 It ) 01 GASOLINE STATION (y) 02 OTHER <br /> 'NUI CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> I <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAY,Ef LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMCf LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> I � <br /> IA. (F'1 01 TANK 1 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 190/ 1 ) UNKNOWN <br /> D. CONTAINER CAPACITY: SSD GALLONS l ) UNKNOWN E. DOES THE CONTAINER STORE: I ) 01 WASTE ("Z PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES 1 02 NO IF YES CHECK APPROPRI"A��TE BOX(ES): <br /> 1 1 01 UNLEADED f 1 02 REGULAR t ) 03 PREMIUM 1 ) 04 DIESEL t ) 05 WASTE OIL lVf 06 OTHER E�QdSw�G <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE It ) INCHES [ ) CM ( ) UNKNOWN <br /> S. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) l�2 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 01 CARBON STEEL ( ) 02 STAINLESS STEEL 1 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM It ) 07 STEEL CLAD t 1 08 BRONZE ( 1 09 COMPOSITE- ( ) 10 NON-METALLIC <br /> t ) 12 UNKNOW) ( ) 13 OTHER: <br /> MSC04-070185 PAGE 1 <br /> 1 <br />