Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 NEW PERMIT f } 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I <br /> OWN ER <br /> ikAY°1cot. <br /> PCR ATION.INOIVIDUAi OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> f J 01 FED ( J 02 STATE f 1 03 LOCAL <br /> �S?REST AC^.RE55 --- CIT ------- STATE - ZIP ��--- <br /> II FACILITY _ ^ <br /> FACILITY NAYIt — DEALER/'}FOREMENISUPEPVI 0$ P f� <br /> STREET ACL^ESS NEAREST CROSS STREET - <br /> 1 d E_ a <br /> I'C.T Y <br /> ZIP <br /> __ ,V, �� <br /> TSAIL NG ADD ESS CITY - STATE ((ZIPx <br /> C-o9� S <br /> RHONE W,ArE4 CODE TYPE OF BUSINESS <br /> f 1 01 GASOLINE STATION ( ) 02 OTHER <br /> NU)✓BER CF CON AINEPS PLrPAL APEAS ONLY TOWNSHIP - - PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS*. N-Ar,E( LAST NAME FIRST) AND PHONE W/APER C DE _�T--- NIGHTS: NAME(LASTNAME FIRST, "I'll PHONE W,AR A CODE - <br /> q�- j t -fib <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. f TAI(K ( 1 02 OTHER: CONTAINER NUMBER -} -- --- ---------- <br /> 13, MANUFACTURER (IF APPROPRIATE) YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: j GALLONS ( ) UNKNOW)( E. DOES THE CONTAINER STORE: ( 1 01 WASTE C 02 PRODUCT - <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WAST OIL ? C 01 YES f 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> vl 1 01 U_:LEADED ( ) 02 REGULAR 1 ) 03 PREMIUM %) 04 DIESEL ( ) 05 WASTE OIL 1 ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICf!NESS OF PRIMARY CONTAINMENT*� - �1 ) GAUGE f I IIlCHES I ) CM ( } UNKNOWN -. -__ _---- <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT I ,Q-2 NON-VAULTED 1 ) 03 UNKNOWN <br /> JC. l 1 01 DOUBLE WILLED t INGLE WALLED ( 1 03 LINED <br /> 01 CARBON STEEL f ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS C 1 04 POLYVINYL CHLORIDE -( J 05 CONCRETE ` <br /> 1 l 106 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE f 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> 1 I J 12 UNKNOWN l 1 13 OTHER' <br /> ri,mQ4-OT 185 4 PAGE 1 <br />