Laserfiche WebLink
PSTATE I <br /> APPLICATION 'FOR PERMIT TO OPERATE UNDERGROUND 5Ti3RAG Tm <br /> t ) 09 LETE FROM FILE (NO FEE) <br /> (Ar) O1 NEW PERMIT t ) 05 RENEWED PERMIT f ) D7 TANK CLOSED VIROMENTAI�I-�_ <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( } 04 MINOR CHANGE (No SURCHARGE) W�-ERVICES <br /> I OWNER <br /> —-— -- - PUBLIC AGENCY ONLY <br /> NAME fCop PCRA ON,IN IVIDUAL-_fl PUBLIC AGENCY) � ( 1 U1 FED ( ) 02 STATE ( ) 03 LOCAL <br /> CIT <br /> STPEET AC7RE55 n Q <br /> 00 <br /> 'II FACILITY <br /> r DEALER/FOPEMEN/SUPEPVISOR <br /> FACI` rt �r,E" <br /> NEAREST CROSS STREETJ/��/- <br /> STREET-7 10<D400tESS i L�� A � f( 0 /S 1 b0-1 S� <br /> CITYJ <br /> L.a 17�r <br /> CITY ST� ZI3 <br /> MAILING ADOPESS qC <br /> PHONE 41•ACE° COD� /� TYPE OF BUSINESS �� <br /> -!] r/� ,(4/�Y 'SIJ g ZC� sQCI { ) 01 GASOLINE STATION ( YY 02 OTHER <br /> NUf',pER OF CONTAINERS <br /> PUPAL AREAS ONLY : TOWNSHIP PANGE SECTION <br /> `III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY ', NAME(LAST NAME FIPSTI ND PHONE W/AREA CODE <br /> NIG H: NA�(tAS,T NAME��T)�AND-PHONE W/AREA GODS <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IIVV DESCRIPTION <br /> A. [/'01 TANK ( J 02 OTHER: CONTAINER NUMBER ' <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> D �,,� IA�eLd�',� YEAR MFG: C. YEAR INSTALLED J`7 ( ) UNKNOWN <br /> 0. COt4TAINER CAPACITY: )D 0 0 p GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE- ( 1 01 WASTE t 02 PRODUCT <br /> F'OOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE�IL ? ( D1 YES ( ) 02 NO <br /> IF YES CHECK APPROPRIATE BOX(ES), <br /> ( ] 01 UNLEADED ( 1 02 REGULAR t ) 03 PREMIUM (✓) 04 DIESEL ( ) 05 WASTE OIL t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 14 { J GAUGE ( yr INCHES ( } CM t ) UNKNOWN <br /> B. t ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) K"02 NON-VAULTED [ 1 03 UNKNOWN <br /> C. t W101 DOUBLE WALLED ( 1 02 SINGLE WALLED f 1 03 LINED <br /> D. (/001 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( } 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM t ) 07 STEEL CLAD ( 1 08 BRONZE ( } 09 COMPOSITE [ } 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> H5C04-070185 `� PAGE 1 <br /> „AF �/ <br />