Laserfiche WebLink
.�,,. • • STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) <br /> 01 NEW PERMIT 1 ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( 1 OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INp IVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> /qVd Q,� Co ( 1 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br /> STREET(`ACORESS (y� CITY STATE ZIP <br /> �LFWTTf166oa Fi TJ 37108 <br /> II FACILITY _ <br /> FACILITv NAME DEALER/FOPEMEN/SUPERVISOP <br /> STREET ACO'ESS NEAREST CROSS STREET <br /> 153 E <br /> CITY —_- --- COUNTY ZIP <br /> 1 aaey SG.Y Joa u, aSIS71 to <br /> QQ G-'1'CQ C,( ,¢G STATE ZIP <br /> MAILING ADDPESS CITY <br /> 9 f5 o-?-3 <br /> PHONE W,APEA CODE Ty P OF BUSINESS <br /> 46t-407 1301 f l 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER CF CONTAINEPSRUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,EILAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> Grfe_1_ L',tid� J09 -P3a" 8815 Green , C uda Jog "835- 1083 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. %) 01 TANK ( 1 02 OTHER: 1 CONTAINER NUMBER 2- <br /> B. MANUFACTURER (IF APPROPRIATE I:MIOD E:fln) lL1QIA - I4STEEL. YEAR MFG:19$� C. YEAR INSTALLED q 8-7 1 ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10,006 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE `A 02 PRODUCT — <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l/l 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (xl 01 UNLEADED l 1 02 REGULAR ( 103 PREMIUM 1 1 04 DIESEL ( 1 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: /C 1 1 GAUGE 06 INCHES ( ) CM 1 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED 1 1 03 UNKNOWN <br /> C. ,rl 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( 1 03 LINED <br /> 0. (�I 01 CARBON STEEL ( 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br /> ( ) 06 ALUMINUM 1 ) 07 STEEL CLAD 1. 1 OB BRONZE 1 1 09 COMPOSITE ( l 10 NON-METALLIC <br /> l 1 12 UNKNOWN l 1 13 OTHER: <br /> HSC04-D70185 -- — -- - . ..PAGE -1 <br />