Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> - ------ -- -- <br /> ( ) 09 DELETE FROM FILE (NO FEET <br /> ( 1 <br /> 01 NEW PERMIT 1 1 OS RENEWED PERMIT l 1 07 TANK CLOSED <br /> l 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE IND SURCHARGE) <br /> I OWNER -- <br /> NAME(COPPORA TION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( I O1 FED f 1 02 STATE ( 1 03 LOCAL <br /> ZIP <br /> STREET ACCRESS CITY STATE <br /> II FACILITY _ <br /> FACILITY NAME DEALER/FOPEMENISUPERVISOR <br /> STREET FCC°ESS NEAREST CROSS STREET <br /> -- COUNTY ZIP <br /> CITY <br /> -- -- CITY STATE ZIP <br /> MAILING ADDRESS <br /> PHONE W'AVEA CODE 2PtjlAL <br /> YPE CF BUSINESS <br /> _ ( 1 01 GASOLINE STATION ( 1 02 OTHER <br /> NVCBEP CF CDNTAZNEcS REAS ONIY TOWNSHIP �RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> E. NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST)-ANO 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 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( 1 UNKNOWN <br /> O. CONTAINER CAPACITY: GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 O1 WASTE I ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 7 1 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOXf ES 1: <br /> 1 1 01 UNLEADED l 1 02 REGULAR t 103 PREMIUM l 1 04 DIESEL t l 05 WASTE OIL l ) 06 OTHER___ <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE f 1 INCHES ( ) CM 1 I UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED ( ) 03 UNKNOWN _ <br /> 01 DOUBLE WALLED ( 1 02 SINGLE WALLED 1 1 03 LINED <br /> D. 1 1 O1 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM 1 l 07 STEEL CLAD ( 1 OB BRONZE l 1 09 COMPOSITE ( l 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER: <br /> -- PAGE 1 <br /> HSC04-070185 <br />