Laserfiche WebLink
A9 `/ \ W STATE ID NUMBER <br />,Y APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK /Y5 0 G <br /> ( 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 DELETE FROM FILE IMO FEET <br /> 1 102 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER -- <br /> NA1:'_(CORPORATZON,INOIVIDUAL OR FVBLIC AGENCY) PUBLIC AGENCY ONLY <br /> D 1 . � ( 1 Ol FED ( 1 02 STATE 03 LOCAL <br /> STREET ADDRESS �j CITY STATE ZIP <br /> — - z 14 31 Fn7 MA-RIMS A J 95"7,�� <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMENISUPERVISOR <br /> -$ . TIT, CBMp <br /> STREET AD -ESS Z �� �L [ � NEAREST CROSS STREET <br /> CITY �v;ov COUNTY ( /TT ZIP <br /> MAILING AODPC S CITY STATE ZIP <br /> p 6, i3a�t L/ Szl3-A� <br /> PHONE WIAPEA CODE TYPE OFBUSINESS <br /> O1 GASOLINE STATION ( i 02 OTHER <br /> NUMBER CF -ONTA�PS -- PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> �DAYS: AY,E(LAST NAME FIRST) NO PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> eun.IA�✓ ll�- ZQ�-4f/- f'GF_/ D/ SJLI« ices `Ls4-�S 266 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> �3 A. 1 1 01 TAN)( ( ) 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED_ ( UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS f I VNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE l ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 <br /> 01 UNLEADED l 1 02 REGULAR 1 ) 03 PREMIUM l i 04 DIESEL 1 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION _ <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE ( 1 INCHES l 1 CM IUNKNOWN _ _— <br /> B. L 1 01 VAULTED (LOCATED IN AN UNOERGRODUO VAULT) 1 ) 02 NON—VAULTED ( 03 UNKNOWN <br /> IC. 1 1 01 DOUBLE WILLED 1 1 02 SINGLE WALLED ( 103 LINED <br /> STEEL f 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE 1 1 09—COMPOSITE- <br /> 9COMPOSITE l 1 10 NON—METALLIC <br /> 1 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070165 PAGE 1 <br /> J <br />