Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> IL-01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED l ) 09 DELETE FROM FILE (NO FEEL <br /> 1 ) 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INOIVZOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> l ) 01 FED 1 1 02 STATE ( ) 03 LOCAL <br /> STREET P.DCRESS CITY STATE ZIP <br /> II FACILITY <br /> FACILITY NAME OEALER/FOP EN/SUPERVISOR <br /> Z1t <br /> STREET ACD�ESS NEAREST CROSS STPEET <br /> CITY COON Y ZIPPY <br /> WA <br /> ( S <br /> M A > CITYSTATE ZIP jr <br /> PHONE Wi APEA CODE TYPE OF BUSINESS rv' <br /> ( 1 O1 GASOLINE STATION � 02 OTHER <br /> NVI!DEA OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NA E(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. 1� 01 TANK ( 1 02 OTHER: CONTAINER NUMBER 2_ <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ) UNKNOWN <br /> D. CONTAINER CAPACITY: (.� GALLONS I ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE 4,N-<,02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? f ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> ( ) 01 UNLEADED f ) 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL W 06 OTHER J9 <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f 1 INCHES ( ) CM &UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. (" ) 01 DOUBLE WALLED ``02 SINGLE WALLED ( ) 03 LINED <br /> 0. ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ] 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 130 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 113 OTHER: <br /> HSC04-070185 PAGE 1 <br /> �..00 <br />