Laserfiche WebLink
STATE TO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> - -�--- ------ -- - --- 1 09 DELETE FROM FILE INO FEE) <br /> t 1 01 NEN PERMIT 1 1 0S REME14ED PERMIT 1 1 07 TAN( CLOSED <br /> _ 1 O2 CONDITIONAL PERMIT —1 100 AMENDED PERMIT 1 1 OB MINOR CHANGE <br /> IIID RIRCIUM[1 <br /> t OWNER _—_— ---- <br /> PlJ4lIC AGENCY ONLY <br /> is •D.ArtoN.iwiviouAl os rlrotie Aotucrt 1 1 O1 FED 1 1 02 STATE I 1 03 LOCAL <br /> STATE air <br /> sr►etr Aoo.a clTrC 5 <br /> II FACILITY _ <br /> OtAlt /OrtMEN/SwttVlSor <br /> /ACIIITT NAM[ <br /> — <br /> N[A.ttT COOS f ST.c[T <br /> tT.!!T aOC•Lff 60 <br /> �irr (z< �ta Naa�cT' -- <br /> :t► <br /> COUNTY <br /> etTr / -- Q <br /> �L�1liL�OOES csrr� Q <br /> STATE zlr <br /> MAILING Aoortst C ,F1 <br /> _4L� _ vte�nrT — -- -- <br /> ..ON! N•A•QA coot T<.E CF oust-Ess <br /> 1 1 <br /> 01 GASOLINE STATION 1x1 02 OTHER <br /> o•NGC SCCTIOM <br /> NLPSt. CF CONTAINERS OUPAL A•EAS ONIV TMIn SAI. <br /> 1II 24 HOUR EMERGENCY CONTACT PERSON <br /> NAME iKT/ AND ►NON! Y/A.aA COOS <br /> OATS: MA"(LAST NAME FI•ITI AND ►NONE N/AOCA CODE NIGHTS: MAM t tAST r <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1V DESCRIPTION --- <br /> A. 1 O1 TANK t 1 02 OTHER: IITCONTAINER (MISER <br /> ---_--_-- - --- YEAR MFG: C. YEAR INSTALLED QI 1 UNKNOWN . <br /> 0. MANUFACTURER IIF APPROPRIATE): u�K,�O��- _ _ - --- --- <br /> 0. CONTA114ER CAPACITY: GALLONS 1 I UNKNOWN <br /> E. DOES THE CONTAINER STORE: 1 ) OL HASTE 0- PRODUCT - <br /> F. DOES THE CONTAINEP STORE MOTOR VEHICL[ FUEL OR WASTE OIL '. 1 1 01 YES 1 1 02 110 IF YES CHECK APPROPRIATE BOKIESI: <br /> 1 O1 UNLEADED I 1 02 REGULAR 1 1 05 PREMIUM 1 1 04 DIESEL I 1 05 WASTE OIL 1 1 06 OTHER ' <br /> V CONTAINER CONSTRUCTION - - - <br /> A. TRIC/NESS OF PRIMARY CONTAPIMENT: - - --- I 1 GAME 1 - I 111CHES 1 1 CM ' UNKNOWN - <br /> 0. 1 1 01 VAULIEO ( LOCATED IN AM UNDERGROUND VAULTY 1 '/ 02 NON-VAULTED I 1 03 UNKNOWN <br /> 1C. 1 1 01 OOUBIE WILLED f) 02 SINGLE WALLED 1 1 OS LINED <br /> O1 CARBON STEEL 11_02 STAINLESS STEEL 1 1 07 FIBERGLASS t 1 04 POLYVINYL CHLORIDE l 1 0S CONCRETE k <br /> —1 1 06 ALLNIIHUM 1 1 07 STEEL CLAD 1 1 06 BRONZE I 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> 1 1 12 L9I(NOWN 1 ) 15 OTHER: <br /> PAGE 1 <br /> NSC04-0:?IBS <br /> • �� ter. <br />