Laserfiche WebLink
STATE IO NUMBER <br /> �--� APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (X) 01 NEW PERMIT l ) 05 RE4EWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 DELETE FROM FILE [NO FEE) <br /> 1 ) C2 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 06 MINOR CHANGE (N0 SURCHARGE) <br /> OWNER <br /> NAnc ORPOR ATIONINDIVIDUAL or ►ueuJ- <br /> Ao encn PUBLIC AGENCY ONLY <br /> 0 'OrC y.`(�(1 - f 1 Ol FED l ) 02 STATE 1 1 03 LOCAL <br /> STREET AD N C STATE :xv <br /> I(001 NO S°WFY1 �tVePt O�nl tt� �aOOCo <br /> II FACILITY <br /> laos D[Al[R/Mf ORoLhaVP[RV <br /> �uNC� re k # n�aehEr <br /> STRFCT ADDRESS NEAREST CROSS STREET <br /> 'CITY`1 COVNT( n IIPq� ? a()`W` J <br /> IMAIIxNLp ADOREss CITY STATE - Iv <br /> e- <br /> 'PHONE W/AREA COO C TYPE Of RusINCSS <br /> (Q,1� R�g _ y i L 1�1 01 GASOLINE STATION l 1 02 OTHER <br /> NUHOCR OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANOC 3l CTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> IOAYS: NAM[I LAST NAME fIRST) ANO ►NONE W/ARCA CODE NiONTi: NAME<IAST NAM[ FIRST) AND PHONE W/AREA CODC <br /> Scln11 (YEAPpf� IM nInar 1 L 1/\ 3�-nCU <br /> _ hs <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> Af <br /> A. 01 TAMC f l 04 OTHER: CONTAINER NUMBER I <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG-* C. YEAR INSTALLED lid uwNOWN <br /> u. LONTAINER CAPACITY: 1D,L G GALLONS 1 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE W) 02 PROOUCT <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL : 0(') 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE <br /> i ( ) 01 UNLEADED (\/) 02 REGULAR ( ) 03 PREMIL)h l ) 04 DIESEL l ) 05 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAIWENT: f ) GAUGE l ) INCHES ( ) CM t}7 LRaCNOFN <br /> 11 B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (,Y) 02 NON-VAULTED 1 ) 03 UNKNOWN <br /> �C. ( ) 01 DOUBLE WALLED f 1 02 SINGLE WALLED l ) 03 LINED <br /> i/) 01 CARBON STEEL 1 ) 02 STAINLESS STEEL t 1 03 FIBERGLASS l ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 ) 07 STEEL CLAD ( ) OB BRONZE 1 ) 09 COMPOSITE ( ) 10 NON-METALITC <br /> 1 ) 12 UNKNOWN 1 ) 13 OTHER: _ <br /> .14-070185 PAGE 1 <br />