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�rC�g STATE ID NUMBER / <br /> APPLICATION FOR PERMIT TO OP ATE UNDERGROUND STORAGE TANK <br /> kA 01 NEW PERMIT ( 1 05 RENEWED PERMIT (Kj 07 TANK CLOSED _ 1 ) 09 DELETE FROM FILE (NO FEEL <br /> I 1 1 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT 1 ) 0 I RANGE (NO SURCHARGE) <br /> I OWNER <br /> HAVE(COOP PORAT ION.INC IVIDUA L OR PUDLIC AGENCY) PUBLIC AGENCY ONLY <br /> Edd 1 e R t ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET AGGRESS 6 C:TY STeyPS�G?Z <br /> II FACILITY <br /> FACILITY NAME fl Ajj- / DEALER/FOREMEN/SUPERR,IS R <br /> STREET ADD-ESS ,v Pf/ NEAREST CROSS STREET <br /> �Z3 S, sn/o frl�tz�G7onJ <br /> CITY C..� COUNTY ZIP 9,f-2 or <br /> MAZlINO AODPESS� �- N �S7 CITY / STA' w ZIP 6 <br /> PHONE W/AFEA CODE TYPE OF DUSINESS {� C_IT <br /> 1 01 GASOLINE STATION ( 1 02 OTHER <br /> NUY.BER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AFEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> Mhxglei 9"va- 11L-17;,' O/ _ _ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. f 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): v- YEAR MFG: C. YEAR INSTALLED A) UNKNOWN <br /> D. CONTAINER CAPACITY: _RV GALLONS [ ) UNKNOWN E. DOES THE CONTAINER STORE: 1 ) 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAIHEk STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l ) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> It 1 01 UNLEADED ) 02 REGULAR l ) 03 PREMIUM ( 1 04 DIESEL ( ) 05 HASTE OIL ( ) 06 OTHER <br /> (V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( 1 CM UNKNOWN <br /> B. It ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) [ 1 02 NON-VAULTED 03 UNKNOWN <br /> C. (\ ) 01 DOUBLE WALLED ( 02 SINGLE MALLEO 1 1 03 LINED <br /> D. l)n O1 CARBON STEEL l 1 02 STAINLESS STEEL l 1 03 FIBERGLASS 1 ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> /�( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> 1 ) 12 UNKNOWN ( ) 13 OTHER: <br /> MSC04-070185 PAGE 1 <br /> L� <br />