Laserfiche WebLink
4 <br /> STATE ID N"ER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (x1 OI NEW PERMIT ( ) O5 RE4EWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> I ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE 4NO SURCHARGE) <br /> I GONER <br /> ;NAME(CORPORATION.IND V;JUAL OR PUBLIC AGENCY' �- PUBLIC AGENCY ONLY <br /> 0; , n L+ IDo V ,f) I I?fl i ) 01 FED ( 1 02 STATE ( 1 03 LOCAL <br /> ISTPEET ADDRESS CIT, STATE ZIP <br /> iI FACILITY <br /> �!►CILITY NAME <br /> DEALER/F,OWEMAN/SUPERVZ R <br /> m 1 er <br /> ISTREET ADDRESS NEAREST CROSS STREET <br /> netl <br /> iCITtlGDUNTYn � r /'} I - ZIP� � <br /> [MAILING ADDRESS CITY v �G STATs< SIP <br /> . T <br /> !PHONE WIAREA CODE TYPE OF BUSINESS <br /> itri ��) _4-7(6 ) O1 GASOLINE STATION l 1 02 OTHER <br /> NUMBER F CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> Ill 24 )TOUR EMERGENCY CONTACT PERSON <br /> �0AYS: NAME(LAST NAME FIRST) AND PHONE W/AR A DOE NIOHTS: NAME(IAST NAME FIRST) AND PHONE W/AREA CODE <br /> i <br /> �JFOLLOWING <br /> O to <br /> COMPLE� THE LLOWI A SEPARATE ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> +A. ( o TANK ( ) 04 OTHER: CONTAINER NUMBER <br /> 6. MANUFACTURER (IF APPROPRIATE): YEAR MFG: /�q I C. YEAR INSTALLED ( ) UNKNOWN <br /> u. CONTAINER CAPACITY: IO,C)()G GALLONS [ ) UNKNOWN E. DOES THE CONTAINER STORE: ( J 01 WASTE ()�1 O2 PRODUCT <br /> GOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (A 01 YES [ ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> i J <br /> 01 UNLEADED i>U 02 REGULAR i ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> `A. THICKNESS OF PRIMARY CONTAINMENT: C 1 GAUGE [ ) INCHES t ) CM V) UwHom <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) [ ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> r <br /> I <br /> C. ( 1 01 DOUBLE WALLED I ) 02 SINGLE WALLED [ ) 03 LINED <br /> O, f X"r)l CARBON STEEL P( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS l ) 04 POLYVINYL CHLORIDE 1 ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 5ROHZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 32 UNKNOWN ( ) 11 OTHER: <br /> i15C04-07hI85 <br /> PAGE 1 <br />