Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> NEW PERMIT ( ) 05 RENEWED PERMIT &�A 07 D ( ) 09 DELETE FROM FILE (NO FEE) <br /> CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT r ) 0$ 0 CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORAT ON.INDIVIDUAL OR UBl C AGENCYG•�) PUBLIC AGENCY 2HLY <br /> )N, L ( ! 01 FED ( 02 STATE (x'03 LOCAL <br /> STREET ACORESS CITY STATE ZIP <br /> 9szzG <br /> II FACILITY <br /> FACT ITY NAME DEALER/FOREMEN/SUPERVISOR _ <br /> 1� r E S <br /> STREET ADDRESS NEAREST CROSS.$TPEET <br /> CITE—�.___ COUNTY -7- ZIPQ <br /> COI O J JO / s�-Zd <br /> MAILING ADDRESS r CITY STAT ZIP <br /> 74 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 91140 Ob 3�o ( ) 01 GASOLINE STATION A&.02 OTHER99=��iojrySC/WG1 <br /> NUMBER OF CONTAINERS RUPAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS' NAME) AST NAME FIRST) AND PHONE W/AREA CODE NIOHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> I'�l `GLY.� xy sbsraro3r ^ M`G, (�e ,z�j36y 3L� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION _ <br /> A. (*'O1 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: SSO GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE Vo 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL a l 01 TES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> f 1 01 UNLEADED 06 02 REGULAR ( ) 03 PREMIUM f ! 04 D ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM lel M1 CNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) QQ 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED S2L.02 SINGLE WALLED ( ) 03 LINED <br /> D. 1,6L.21 CARBON STEEL [ 1 02 STAINLESS STEEL ( l 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD f 1 08 BRONZE 1 ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> i <br />