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v <br /> STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> CX 01 NEW PERMIT l ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED 1 109 DELETE FROM FILE (NO FEE) <br /> 102 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 00 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAM11CORPJJORATION.INDIVIDUAL 00 PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> OI✓ y'Tj / �Yb (Xi 01 FEB f ) 02 STATE f 1 03 LOCAL <br /> STREET ADDRESS <br /> CITY STAT <br /> II FACILITY <br /> ,._ 0[A ER/FORCMEN/SUP RVISOp <br /> �S n!!T AOO P[SS . � NEAREST CROSS STREET <br /> �C'Ts J COUNTY <br /> _ C\J ZIP <br /> MAILING ADDRESS CITY ST TC ZIP <br /> G <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION (XI 02 OTHER 17 e r <br /> NMBIN OF CONTA.TNEq$ PUPAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 2��4 HOUR EMERGENCY CONTACT PERSON <br /> iOA 5 <br /> FIRST) ANDYONEji=EA �0� � NIOMTSt NAME(LAST NAME FIRST)-AND-PHONE W/APEA CODE <br /> COMPLETE THE FOLLLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> r- <br /> iA. (A 01 TAM( f 1 02 OTHER: CONTAINER NUMBER <br /> !B. MANUFACTURER (IF APPROPRIATE): YEAR MFG:VNK C. YEAR INSTALLED / 1 ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS 1 ) IRMMOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (X 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BO%IES1: <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM A04 DIESEL ( 1 OS WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> IA. THICKNESS OF PRIMARY CONTAINMENT: 1 ) GAUGE ( 1 INCHES ( ) CM lX UNKNOWN <br /> !B. ( 1 01 VAULTED (LOCATED <br /> ���J///IN AN UNDERGROUND VAULT) 1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> ;IFC. ( 1 01 DOUBLE WALLED (q 02 SINGLE WALLED 1 1 03 LINED <br /> ,D. 101 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ! 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 06 ALUMINUM ( 1 07 STEEL CLAD 1 1 OB BR014ZE 1 ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> f 1 12 UNKNOWN l l 13 OTHER: <br /> MSC04-070185 - - -- -- —_—� --- PAGE 1 <br /> L � �" <br />