Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ' 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET AC'7RES5 CITY <br /> STATE ZIP <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPERVI OR <br /> No z <br /> STFEET ACC ESS NEARESTCROSS S PEET <br /> CITY COUNTY ZIP <br /> yS <br /> Ll <br /> MAZLING ACDPESS CITY STATE ZIP <br /> no c <br /> PHONE W•ACEA CODE TYPE CF BUSINESS <br /> GASOLINE STATION ( 1 02 OTHER <br /> NUMBEP CF CONTAINEPS -- PUPAL AREAS ONLYTOWNSHIP -- PANGE SECTION - -- <br /> - - - - - -- <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAI'E( LAST NAME FIPST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> - �� --- -915- 37I 'a�1.2 9RCo i�V�ain�r►�aK�P -- <br /> zoo­uil4S <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 01 TA)OC ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): 'I YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: b D GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE L04 02 PRODUCT —_ <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? b<01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES)- <br /> 'xI 01 Uf:LEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TN.ICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM 9.ct UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> IC. MjQ 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. 1 ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL D4. 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> II 1 ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER: <br /> H5C04-0;^185 PAGE 1 <br />