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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1' { 01 NEW PERMIT ( ) 05 RENEWED PERMIT (>t 07 TANK CLOSED ( ) 09 DELETE FROM FILE IND FEE1 <br /> 1 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 04 -IRM-MANGE (NO SLIRCNARGEI <br /> I OWNER <br /> NAM!(C RPORATION.INDI IDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> G f ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STAT ZIP <br /> Q <br /> II FACILITY <br /> FACILj TY NAME DEALER/FgPEMENISUPER ISOR <br /> 2/ r 156 Y ( <br /> ,STREET AOL'E S NEARS T CROSS STREET <br /> CITY COUNT ZIP <br /> fur <br /> MAI LI NO D DS CITY JD STATE ZI <br /> 00 <br /> PHONE W/ATEA CODE TYPE OF BUSINESS L/- <br /> = - l 1 <br /> 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CO TAZHERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NA/Y.Ef/lAS NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 7W ( M-5- re-- 3ft0/07 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A.,( 6 01 TAMC f 1 02 OTHER: CONTAINER HUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 4.0 <br /> UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS1 UNKNOWN E. DOES THE CONTAINER STORE: ( 01 WASTE t ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR 1 ) 03 PREMIUM ( ) 04 DIESEL li<l 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE I ) INCHES ( ) CM Vd,UNKNOWN <br /> S. ( 1 01 VAULTED ILOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( I O1 DOUBLE WALLED ( ) 02 SINGLE WALLED l 1 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( ) 06 ALUMINUM 1 ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1t$ X42 UNKNOWN ( ) 13 OTHER: <br /> MSC04-070185 PAGE 1 <br />