Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT - f ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) <br /> 01 FED ( 1 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS CITY STATE IIP <br /> E <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> STREET ADC'ESS NEAREST CROSS STREET <br /> L / <br /> CIT COUNTY ZIP <br /> akgff� IMAILING ADOPESS CITY STATE ZIP <br /> ! S <br /> PHO 'E .W AC EA CODE TYPE OF BUSINESS T <br /> - ( ) 01 GASOLINE STATION !.YJ 02 OTHER <br /> NVMBER CF C7NTA2 NERS RVRAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAY f,� LAS /FIRST) AND ONE W/AREA CODE NIGHTS: NAME(IAST NAME FIRST) AND PHONE W/AREA CODE <br /> Lem ��PH7 S � Z <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 1 TAMC f 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG:' C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN I E. DOES THE CONTAINER STORE: ( 1 01 WASTE (W 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ja 01 YES ( l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED ( ) 02 REGULAR ( 1 03 PREMIUM 1 04 DIESEL ( 1 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( l GAUGE f 1 INCHES ( ) CM f UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (C) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( I 01 DOUBLE WALLED %0. 02 SINGLE WALLED ( 1 03 LINED <br /> D. 'l01 CARBON STEEL ( 1 02 STAINLESS STEEL f ) 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> J( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE f ] 10 NON-METALLIC <br /> t ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br /> e J <br />