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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 61 NEN PERMIT 1 1 OS RENEMEO PERMIT 1 1 07 TANK CLOSED ( ) 09 OELETC FROM FILE (NO FEETt <br /> ( 1 02 COtlDITIONAL PERMIT -1-1 06 AMENDED PERMIT 1 1 OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> MAM!(COPPORATION.INOIVIDU4L <br /> (/IAGENCY) <br /> II I PUBLIC AGENCY ONLY <br /> JD /u <br /> d✓✓Ta �p , 1 1 01 FEB 1 1 02 STATE 1 1 03 LOCAL <br /> STILET ACD9ESS - CIT STAT! ZIP <br /> CA <br /> II FACILITY <br /> FACILITY NAME— O! P/IlN� I! W — <br /> 9-3 4- ,rnL _ <br /> STPEET ACC°CSS NEAPEST CR SS STFEET <br /> CITY COUNTY - <br /> MAILING APIP'6 CITY Z; y o y <br /> PHONE W"TAtfA CODE TYPE OF BUSINESS (�� <br /> -2 og -333 -' Ix. 01 GASOLINE STATION 1 1 02 OTHER <br /> NUr8EP Of CONTAINERS 3 PUPAL APEAS ONLY : TOWNSHIP PANG! SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIP TI AND ►NONE W/APEA COOL NI0 TS: NAME(LAST NAME FIRST) AND PHONE WIAFEA COO! <br /> 7o7 2z fir; d �� ^�+, rr,�, - saw - N z 1 -� 4s <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION �] <br /> p A. 1 O1 TAW 1 1 02 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER IIF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 19 8'Z( 1 UNKNOWN <br /> D. CONTAINER CAPACITY_ GALLONS ! UNKNOWN E. DOES THE CONTAINER STORE: I 1 01 HASTE 1x1 02 PRODUCT <br /> F. 05 Tfif CONTAINER E MOTOR VEHICLE FUEL OR WASTE OIL ? (JS49C YES 1 1 02 NO IF YES CHECK APPROPRIAT BO%(ES): <br /> UtLEADCD ( 1 02 REGULAR ( 1 03 PREMIUM ( 1 04 OIkSG l 1 05 WASTE OIL -1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> 4. THICKNESS OF PP.IMARY CONTAINMENT: 0 �2�0 1 1 GAUGE RHES 1 ) LM 1 1 t1NKHOWN <br /> B. I 1 01 VAULTED (LOCATED IN AN UNOERGROU)ID VAULT) (kvO NON-VAULTED 1 1 03 UNKNOWN <br /> IC. ( 1 01 DOUBLE WILLED 1 02 SINGLE WALLED' 1 1 03 'LINED <br /> D. ( 1 01 CARBON STEEL 1 1 02 STAINLESS STEEL IY;116 FIBERGLASS 1 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( 1 06 ALUMINUM I 1 07 STEEL CLAD 1 1 Gtr RONZE 1109 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 U14KNOWI( l 1 13 OTHER: <br /> MSC04-070185 PAGE i <br />