Laserfiche WebLink
STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT ( 1 OS RENEWED PERMIT l 1 07 TANK CLOSED l 1 09 OELETE' FROM FILE tN0 FEE) <br /> 1 1 02 CONDITIONAL PERMIT _1 1 06 AMENDED PERMIT t ) 08 MINIM CHANGE (NO SURCHARGE) -_- <br /> I OWNER <br /> N•M!(COP ORATI N.INDIVIDUAL OR FUEL AGENCY) Pl18LIC AGENCY ONLY -- - <br /> / <br /> 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> . STeEET A Cn QZ SS CITY�sc�a� T�TATS ZIS�3� <br /> c <br /> II FACILITY <br /> FACILIT NAME DEA ER/F EMEHfSUPERVISOP <br /> STREET ADD°ESS NEAREST CROSS STREET <br /> CITY n COUNTY ZIP <br /> Lah`.13 <br /> V\ 53 <br /> as <br /> ..+ <br /> �l MAILING - , CIT C n 1-644-STATE 7 <br /> �J31?b <br /> PHONE W%ACODE �- YP OF BUSINESS <br /> ZA.Gt _ J 4� t 01 GASOLINE STATION I 1 02 OTHER <br /> NUMBER CF CONTAINEPS PUPAL AP EAS ONLY TOWNSHIP PANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS' NAME(lAS NAME orPSTI A PHO$(E W/APER CODE NI NTS: NAME(LASJ NAME FIRSTI AND PHONE W/A)E COD <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( O1 TANK [ 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE)' YEAR MFG: C. YEAR INSTALLED j (pOip <br /> �( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: ��(�� GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01.WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> ( 0 ADED ( 1 02 REGULAR t ) 03 PREMIUM t 1 04 DIE EL ( 1 05 WASTE OIL ( l 06 OTHER — <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES ( 1 CM 1 1 UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNOERGROUND VAULT) '( -VAULTED ( 1 03 UNKNOWN <br /> ,C. ( 1 01 DOUBLE WILLED ( O NGLE WALLED l 1 03 LINED <br /> D. ( O1 CARBON STEEL t 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> ( ! 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />