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7f <br /> STATE I0 NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND 5TORAGE TANK <br /> % 10I NEN PERMIT 1 1 05 RENEWED PERMIT i 1 07 TANK CLOSED { 1 09 OELETC FROM FILE (NO FEET <br /> { 1_02 COttOITIONAL PERMIT 1 1 06 AMENDED PERMIT 1 1 08 MINOR CHANGE 1NO SURCHARGE) <br /> I OWNER <br /> NA►•,E1CO00ORATION,IN0IVIDUAL OR PUBLIC AGENCY PU9LIC AGENCY ONLY <br /> { 1 02 STATE 1 1 03 LOCAL <br /> STREET ACO4EIS --74 EC <br /> TY STAT! J�� <br /> II FACILITY <br /> rACIIITY NAME DEALER/POPEMEN�SUPEPVISOP <br /> STREET AOL'IfSS NEAREST CROSS STREET <br /> CITY � COUNT S , � ZiP © <br /> 4 <br /> ' MARINO AL'DPESS CITY STATE ZIP r+ <br /> PHONE W•AREA CODE TYPE OF BUSINESS <br /> 1 01 GASOLINE STATION ( 02 OTHER <br /> s <br /> } <br /> Ni CP CONTAINERS _ RURAL AREAS ONLY FOM?ISMIR 'RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEE( L-A$T�NAME <br /> ?FIRST) <br /> )AND PMONS�gWIA/REA CODE RIO14TS: NAME(L►ST NAME FIRST ) AND PO4ONE N/AARJEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IVDESCRIPTION <br /> i <br /> ' A.-15C► O1 TAti1K 1 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER fIF APPROPRIATE )' YEAR MFG. C. YEAR INSTALLED �� �� if 1 UNKNOWN <br /> 0. CONTAINER CAPACITY`le G (J(J GALLOttS 1 1 UNKN(Ml JE. DOES THE CONTAINER STORE: 1 1 01 WASTE l 1 02 PRODUCT --- <br /> F, DOES THE CONTA114ER STORE NOTOR VEHICLE FUEL OR WASTE OIL ? i 1 01 YES 1 1 02 NO IF TES CHECK APPPOPRIATE BOx1ES1: <br /> I 1 01 UNLEADED (><r02 'REGULAR i 1 03 PREMIUM f 1 04 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TH[Ctt1E55 Of PP.IMARY CONTAINS-EHT: 1 1 GAUGE 1 1 INCHES f I CM l LPNKNOwt1 <br /> I <br /> J8. 1 t 01 VAULTE0 1 LOCATED I" Art UI:OERGROUNO VAULT 1 1 M 02 NON-VAULTED 1 1 03 LRIKNOWN <br /> i <br /> 1{{{C. f 1 01 00VOLE WILLED 1y 02 SI14GLE WALLED 1 1 03 LINED <br /> D. 0<1 01 CARBOt1 STEEL 1 1 02 STAINLESS STEEL f 1 03 FI6ERGLASS f 1 04 POLYVINYL CHLORIOE 1 1 05 C014CRETE <br /> 1 1 06 ALUMINUM 1 1 07 STEEL CLAD f 1 08 BRONZE 1 i 09 COMP05ITE 1 1 10 NON-METALLIC <br /> I 1 12 U1IKNOWH 1 1 13 OTHER: <br /> ,I;�oo-0; 195 PAGE 1 <br />