Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) <br /> 01 NEW PERMIT ( ) OS RENEWED PERMIT (>d"07 TANK CLOSED <br /> 1 ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT t 1 06 AMENDED PERMIT ( 7 08 MINOR CHANGE (NO SURCHARGE) <br /> I OPINE <br /> PUBLIC AGENCY ONLY <br /> NAMEICOR POR/)IION.IND INDIVIDUAL OR PUS IC AGENCY) ( ) O1 FED ( ) 02 STATE, I-FT03 LOCAL <br /> SQf\ �� lAA �l.P`N T- <br /> CITy�� STATE ZI�Pj f� <br /> STREET ADDRESS <br /> C S'S20Z <br /> 2�z E• U/¢ber <br /> II FACILITY <br /> DEALER/FOREMAN/SVPERVISOR <br /> FACILITY NAME <br /> NEAREST CROSS STREET <br /> STREET ADDRESS <br /> COUNTY ZIP <br /> CITY <br /> CITY STATE ZIP <br /> MAILING ADDRESS <br /> TYPE OF BUSINESS <br /> PHONE W/AREA CODE ( ) Ol GASOLINE STATION t 7 02 OTHER <br /> NUMBER OF CONTAINERS URAL AREAS ONLY TOWNSHIP <br /> RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CCDE NIGHTS: NAMEILAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> CONTAINER NUMBER <br /> A. ( 7 Ol TANK ( 1 04 OTHER: <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLED UNKNOWN <br /> ( ) <br /> 0. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 7 O1 WASTE ( ) 02 PRODUCT <br /> CHECK <br /> F. DOES THE <br /> ULEADEUWE( STOR <br /> 02EREGULARVEHICLE <br /> 03FUEL <br /> PREMIUMWASTE <br /> T 04OIL <br /> DIESEL 0l )YES <br /> 05 WASTE2No OIL (II 06YES <br /> OTHER APPROPRIATE BOX(ES): <br /> 01N <br /> V CONTAINER CONSTRUCTION <br /> FTHICKINESS OF PRIMARY CONTAINMENT: ( ) GAUGE [ 1 INCHES t ) CM l ) UNKNOWN <br /> AULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED t ) 03 UNKNOWN <br /> OUBLE WALLED ( ) 02 SINGLE WALLED l 103 LINED DE L CHLORIDE <br /> 6RAOLUMITNUML STAINLESS <br /> S(E7L08( 03 BRONZEFIDE;G09SS 04 COMPOSITE �Lrv10YNON-METALLIC( ) 05 CONCRETENKNOWN ( ) 13 OTHER: PAGE 1 <br /> HSC04-070185 <br />