Laserfiche WebLink
STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> fY) <br /> 01 NEW PERMIT 1 1 05 RENEWED PERMIT 1 1 07 TANK CLOSED - ( 1 09 DELETE- FROM FILE (NO FEE) <br /> _1 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE IND SURCHARGE) <br /> I OWNER <br /> NAME�RPORAT2 INDIVIDVAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> AAP(U8, 01 FED 1 1 02 STATE ( ) 03 LOCAL <br /> STREET ACDRESS CITY STATE 22► <br /> amouracl� <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMENISUPERVISOR <br /> NIAP.CST CROSS STREET <br /> 1 4C. .1h 1f , <br /> 0W 4PMV(4 ZIP <br /> 7 <br /> MAILING ADDRESS CITY /��� $TA [ ZIP <br /> ocic1 Vw <br /> PHONE W'APEA CODE TYPE OF BUSINESS <br /> ( 1 <br /> 01 GASOLINE STATION (,Y! 02 OTHER _h40Aj' frSpW(t <br /> NUHBTAIN <br /> pluplL <br /> ARDS ONLY TOWNSN IP RANG! SECTION <br /> III 26 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEILAST NAME FIRST) AND PHONE W/APEA CODE NIONTS: NAMEILAST NAME FIRST) AND PHONE WIAREA CODE <br /> �riK_ YWM7 - - - �tJrF�t�l(r� �J9WE4F -W-RIU7 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (V 01 TANK ( 1 02 OTHER) CONTAINER NUMBER� <br /> B. MANUFACTURER (IF APPROPRIATE): U A1�„�,1' YEAR MFG C. YEAR INSTALLED( ( ) UNKNOWN <br /> m� I�u�-W�Jlun i <br /> D. CONTAINER CAPACITY: _22_ GALLONS l I UNKNOWN E. DOES THE CONTAINER STORE: 1 1"01 WASTE 1X 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ()6 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> 1 1 <br /> 01 UNLEADED l ) 02 REGULAR l 1 03 PREMIUM (X 04 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TMICY.NESS OF PRIMARY CONTAINMENT: 1 ) GAUGE f i INCHES ( 1 CM ( flUNKNOWN! <br /> VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 1v 02 NON-VAULTED ( 1 03 UNKNOWN <br /> IC. f 1 01 DOUBLE WALLED (f) 02 SINGLE WALLED f 1 03 LINED <br /> D. IKI 01 CARBON STEEL l ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( t 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 1 1 06 ALUMINUM 1 ) 07 STEEL CLAD 1 1 08 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> l 1 12 UNKNOWN ( 1 13 OTHER: <br /> MSC04-070185 PAGE 1 <br />