Laserfiche WebLink
f1 0 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Ol NEW PERMIT ( 1 05 RENEWED PERMIT 1 1 OT TANK CLOSED I ) 09 DELETE' FROM FILE tNO FEEL <br /> 02 CDNOITIONAL PERMIT ( 1 06 AMENDED PERMIT 1 1 08 MINOR CHANGE IND SURCHARGE) <br /> DWNER _ ---- - - <br /> .E( OPPORATION,IHCIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 -�� � 1 1 O1 FED 1 1 02 STATE l 1 03 LOCAL <br /> �/ tJ 3rajTE� zIP <br /> PECO ACRPESS _ j� CIT�J ��-" <br /> II FACILITY <br /> FACILITY NAME _ DEALER/FOPEMEN,SUPERVISOR <br /> 3-FEET ACCESS NEAREST CROSS S7PEET <br /> _ '���_ /'��✓�-s.�/r� _ /�'./2�- rte' <br /> CITY COUNTS IIP r <br /> MCITY STATE ZIP <br /> AILING ADDVE55 Zf <br /> "ONE W%AcEA CODE TYPE OF BUSINESS <br /> 2 l 1 01 GASOLINE STATION { 02 ETHER <br /> NVl'BEP CF CONTAINERS PUPAL APEAS ONLY TOWNSHIP PANG! 7 SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(),AST NAME /IPST) AND PHONE W/APEA CODE NIGHTS: NAME LAST NAME FIRST) AND-PV ONE.W,'A A � <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION - -- <br /> A. q 01 TAIIK f ) 02 OTHER= CONTAINER NUMBER j-7�/ <br /> r/ / 7 <br /> B. MANUFACTURER IIF APPROPRIATE)" YEAR MFG: C. YEAR INSTAL-^^ l_I UNKNOWN <br /> 0, CONTAINER CAPACITY: ! GALLONS 1 I U KNO=EDOESTHECONTAINER STORE: t 101 WASTE t 1 02 PRODUCT —s <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR HASTE OIL ? { ) 01 YES 1 ) 02 NO IF YES CHECK APPROPRIATE BOXfESI" <br /> 01 UYILEAOED t 102 REGULAR ( 1 03 PREMIUM4 DIESEL l i 05 WASTE OIL -1 ) 06 OTHER---_ -__ <br /> V CONTAINER CONSTRUCTION __�_------ ---- <br /> A. THICY,#IESS OF PRIMARY CONTAINMENT: — - Iv1 GAUGE 1 I INCHES I I CM I } UNKNOWN <br /> 8. 1 1 01 VAULIE11 1 LOCATED IN AN U1}DERGROUIID VAULT I IXI 02 NON-VAULTED 1 1 03 UNKNOWN - <br /> i <br /> €C. ( V 01 DOUBLE WkLLEO ( ) 2 SINGLE WALLED _{- )-03-LINED <br /> D. I3.-CARBON STEEL I 1 02 STAINLESa STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f ) OS CONCRETE <br /> t ) 06 ALUMINUM f 1 07 STEEL CLAO l 1 08 BRONZE 1 ) 09 COMPOSITE 1 1 10 NON-METALLIC — <br /> f 1 12 U14KNUWII t ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 <br />