Laserfiche WebLink
• • STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f, 1 O1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 1 09 DELETE FROM PILE (NO FEE) <br /> 2 CONDITIONAL PERMIT- 1 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) - <br /> I -OW N E R --- - --- - - -- -- <br /> I-l-T--]- <br /> 4YtC <br /> OR <br /> POPATION,INCIVIOU4l OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> �b C ��--� OL 1- �� ---- ( ) Ol FED 1 102 STA E f 1 03-LOCAL <br /> TAD^RESS �--� CST STATE ZIP <br /> 11..L3 �— �o c la> CC �`fi SSS <br /> II FACILITY _ <br /> IthFACILITY NAPE �-r- DEALLEP/FCPEMEN/SUFEPVISOP <br /> STREET Z'L'L'EE53 ,/� ) NEAPE 5 STREET <br /> CITY <br /> COUNTY -+ Z <br /> MAILI G ADDRESS CITY STATE ZIP� <br /> —lH S S c C <br /> RHO r W I-e CODE TYPE OF BUSINESS - - <br /> Ol GASOLINE STATION (X) .02 OTHER <br /> NUMBER CF CONTAINERS . 'TRT AREAS ONIY TOWNSNID RANGE SlCTSON <br /> III 26 HOUR EMERGENCY CONTACT PERSON _ <br /> OATS: NAr E) LAST NAME FIRST) AND PHONE W/AREA CO E c, NI GHHTT'S.. NAME(LPST NAME FIRST) AND PHONE WIPEA CODE -- <br /> COMPLETETHE FOLLOWING A E A ATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 _0 _ tlK ( 102 OTHER CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ' 1 ( 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: LS l ) UNKNOWN E. DOES <br /> ,�THHE"CONTAINER STORE: ( ) 01 WASTE ) 0 PRODUCT <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL L4-,f rr YES 1 ) 02 NO IF YES CHECK APPR PRIATE BOX(ES): <br /> 1 _ LEADED l 1 02 REGULAR ( 1 03 PREMIUM 1 1 04 DIESEL l 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> (A. THICKNESS OF PRIMARY CONTAINMENT: 1 ) GAUGE 1 1 INCHES 1 1 CM 1 I UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 02 NON-VAULTED 1 l 03 UNKNOWN <br /> JC. ( DOUBLE WALLED ( ) 02 SINGLE WALLED 1 1 03 LINED - <br /> 0, l�l CARBON STEEL 1 1 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 1 OE ALUMINUM l ) 07 STEEL CLAD l 1 08 BRONZE 1 1 09 COMPOSITE ( ) 30 NON-METALLIC <br /> t 1 12 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> }I�r 04-Oi0185 <br />