Laserfiche WebLink
STATE I() NUM*3F.F, <br /> APPLICAT10N FOR PERMIT TO Or•LLRATE UNDERGROUND STORAGE TANK <br /> (--- <br /> 01 NE'.( PFRNIT -- ----( ) 05 RENEWED FLRMIT ( ) 07 TAM CLOSED -------- t ) 09 DELETI' FPOM FILE (NO FEE) l <br /> 02 CG'r70ITIUNAL i'ERMIT ( 1 Oo AML_7r 7 P[f:f:1' ( ) 03 MINOR CHANGE 1113 SURCHARGE) - <br /> J <br /> I OONEP, <br /> ME(COR,O?<.-IC1: INOIVIDUA OR PUBLIC AGENCI' <br /> I t'4 — j� L � CoUBS IC A.ED f ONLY <br /> 1�J - ( 1 OI FED ( J 02 S'I"ATE ( ) 03 LOCAL <br /> �/ (.H, �. � <br /> !STPLET ADO:'ESS5 % r � � CI'f l' STATE ( — ZIP <br /> 11 FACILITY <br /> .FACILITY 1:4ME DEALER/FOREMAN/SUPE ISGP <br /> _ Avco 6 O 2-a «s <br /> iSTPEET ADDPESSNEAPEST CROSS STREET - <br /> i I �. 7t', <br /> - �(� 22� <br /> ICSTY --� -- <br /> h le <br /> COUNTY ZIP <br /> a4i ccL ct <br /> 1raILINv RE-S CIT i STATE <br /> CA �� v0------------ � <br /> PHONE W/AREA CODE iTYP OF BUSINESS —- — -� <br /> 3 TI <br /> 01 GASOLINE STATION ( ) 02 OTHER <br /> 1t.,-5EP OF CONTAII;EPS 3 RURAL AREAS ONLY TOWNSHIP RANGE tEC7I01: -- i <br /> J <br /> ZIT 24 HOOR EMERGENCY CONTACT PERSON <br /> �CAiS: NAM!(LAST NAME F '?ST) AND P WE k/AREA CC,—_ HIGH S: NAME(LP T•NAME FIRST) AND PHONE 'U/AREA CCDF <br /> 2�fl <br /> - ��7 — 4 66c_a y. Co,C��- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> 1V DESCRIPTION <br /> 04 OTHER: CONTAINER HUMBER �- <br /> o. MA1-11ALTURER (IF APPROPRIATE): YEAR MFG C. YEAR INSTAl.LED�97'7(_) Ut0:N0r): <br /> 10. CONTAINER. CAPACITY: () �V GALLONS ( ) Ut,'KN01,N E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( 0 FPO0UCT <br /> i----------- ---- - --' - —..- <br /> �F. DOES THE CON.AINER STORE MOTOR VEHJ LL FUEL OR WASTE OIL ' YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES)'.( ) <br /> 01 UNLEADED ( ) 02 REGULAR ( 03 lIUM ( ) 04 OTn L '( ) 05 WASTE OIL 06 OTHER <br /> V CONTAINED; CONSTRUCTION f" <br /> Ik. THICF:NESS OF FR.U1kRY CONTAINMENT: 0,2�� ( ) GAUGE ( (ES ( ) CM (-) `•(KNOWN -- <br /> t � <br /> I <br /> ;E. ( ) 01 VAULTED (LOCATED IN A14 UNDERGROUND VAULT) D,;-VAULTED ( ) 03 UNKNOWN <br /> JC. ( ) 01 DOUBLE 1.AL'LED�(A tZ-& : <br />