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0 0 STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />OB NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 06 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(COPPORATION.INOIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />( 1 01 FED ( 1 02 STATE ( 1 03 LOCAL <br />$TR ET ADDR S CITY STATE ZIP <br />II FACILITY <br />FACI ITY NAME <br />01 TAMC ( 1 02 <br />DEALER/FOPEMEN/SUPERVISOR e_� <br />01 <br />CONTAINER NUMBER <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />STREET A00PE S <br />0. <br />NEAREST CROSS STREET <br />( GALLONS t <br />7 <br />E. DOES THE CONTAINER STORE: ( ) 01 WASTE 1,102 PRODUCT <br />F. <br />DOES THE CONTAINER <br />( 1 01 UNLEADED ( <br />CITY <br />FUEL OR WASTE OIL ? 14 01 TES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />PREMIUM (,,& 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />COUNTY <br />�J r/- <br />12 <br />ZIP <br />MARINO ADDP <br />CITY <br />STATE ZIP <br />,SS�� <br />1 ✓!L <br />PHONE W/AVEA CODE <br />TYPE OF BUSINESS � <br />1 01 GASOLINE STATION ( 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />[DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />01 TAMC ( 1 02 <br />OTHER <br />01 <br />CONTAINER NUMBER <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. YEAR INSTALLED t)--) UNKNOWN <br />0. <br />CONTAINER CAPACITY: <br />( GALLONS t <br />) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( ) 01 WASTE 1,102 PRODUCT <br />F. <br />DOES THE CONTAINER <br />( 1 01 UNLEADED ( <br />STORE MOTOR VEHICLE <br />) 02 REGULAR ( ) 03 <br />FUEL OR WASTE OIL ? 14 01 TES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />PREMIUM (,,& 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />) CM tid UNKNOWN <br />B. ( ) <br />01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (Lef 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. ( 1 <br />01 <br />DOUBLE WALLED ),02 SINGLE WALLED ( 1 03 LINED <br />D.lb <br />01 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS t ) 04 <br />POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />( <br />) <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE <br />( 1 10 NON-METALLIC <br />( ) <br />12 <br />UNKNOWN ( ) 13 OTHER: <br />HSC04-070185 <br />PAGE 1 <br />