Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( l 09 DELETE FROM FILE (NO FEE ) <br /> l ( 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> N�AKEICOp PORATION.INCIVIDU4L OR PUBLIC AGENCY) PUBLIC AGENCY ONLY 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> ISrpEET AC^PE;S CITY ]STATEanc��._ �1 �_ c� f- Q <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPERVI P <br /> I <br /> !STREET ACC"ESS t NEAREST CROSS STP T <br /> Ac on <br /> �C,TY COUNTY ZIP <br /> �.,�ILING AOOPESS CITY STATE ZIP <br /> �ileONE W-ATEA CODE TYPE CF BUSINESS <br /> 01 GASOLINE STATION ( 1 02 OTHER <br /> INvrDEo CF CONTAS?1EC5- ---- pUPAI AREAS ONLY �TOWNSNIP — — PANGS SECTION— <br /> )III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS, NAr,E(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> __ oz_ - -4/�_ s 2% -04-2 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> i <br /> A. ;,d 01 TAtIK ( 1 02 OTHER: CONTAINER NUMBER v- <br /> I3 MANUFACTURER (IF APPROPRIATE 1= (�k�yi5__ �v h �n YEAR MFG:�ry& C. YEAR INSTALLED/Q{/"/ ( 1 UNKNOWN <br /> ID_CONTAINER CAPACITY:/;,L-7 EDGALLONS ( 1 UNKNOWN JE. DOES THE CONTAINER STORE: 1 1 01 WASTE 02 PRODUCT — <br /> F DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? XI 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 U:LEADED l 1 02 REGULAR " 03_MEMUOL&1 04 DIESEL [ ) 05 WASTE OIL l ) 06 OTHER -� <br /> V CONTAINER CONSTRUCTION <br /> A. THICKt1E.SS OF PRIMARY CONTAINMENT: — ( 1 GAUGE ( 1 INCHES ( ) CM IDA UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) &4,02 NON-VAULTED [ 1 03 UNKNOWN <br /> !C. 01 DOUBLE WILLED [ 1 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL 03 FIEERGLASS ( 1 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE I 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER: <br /> H5C04-07'1185 PAGE 1 <br />