Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION ,FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( �f ( ) 05 RENEWED PERMIT t ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ()I NEW PERMIT <br /> 1 } 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT f ) 0$ MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> T� BLIC AGENCY ONLY <br /> NAY,'cCOPpC TION,INCyVIDUAL 05V PUBLIC AGENCY 01 FED [ ) 02 STATE ( 1 03 LOCAL <br /> CITY STA ZIP <br /> STREET AD KESS <br /> I FACILITY <br /> FACILITY A ,E .I - DEALER/FOPEM N/SUPEPVIS . <br /> NEAPEST CR 5 STREET <br /> STREET Act" <br /> CCUNTY - ZIP <br /> CITY11 <br /> CITY ST TE ZIP <br /> MAYLING A QPESS <br /> PHONE WiACE• CODE f TYPE OF BUSINESS <br /> 01 GA50LINE STATION (if 02 OTHER <br /> NUN ER CF C?NTAI�PS <br /> RURAL AREAS ONLY : TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: ME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST_ -NAME FIRST) AND PHONE W/APEA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCP,IPTION <br /> A. { `) ZIC CONTAINER NUMBER <br /> t 1 02 OTHER= <br /> B. MANUFACTURER (IF APPROPRIATE) YEAR MFG= / C. YEAR INSTALLEDUNKNOWN <br /> / ( ) <br /> D. CONTAINER CAPACITY= UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE 2 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (v" YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES) <br /> ( L-1 O1 UNLEADED I 1 02 REGULAR t ) 03 PREMIUM 04 DIESEL L ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( 1 CM (UNKNOWN 3 <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1�2--NdN-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED GLE WALLED t i 03 LINED <br /> D. lam) CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( i 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> { ) 06 ALUMINUM I ) 07 STEEL CLAM ! 08 BRONZE f ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: e ' <br /> PAGE 1 <br /> HSC04-0:0185 <br />