Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> OONE R <br /> NAME(CQPPORATION,INDIV;PUAL OR PUBLIAGENCY) PUBLIC AGENCY ONLY <br /> (>Cr 01 FED 02 STATE 03 LOCAL <br /> STATE ZIP <br /> STPPT ADDRESS <br /> o —ICITY <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> NEAREW CROSS ST EET <br /> STPEE�T,ADDPESS <br /> VOL(,e <br /> CITY COUNTY ZIP <br /> CLArl&I- tn� <br /> Cq V,) <br /> MAILG A OR- CITY STATE ZIP <br /> Ano C) <br /> 0 �ss O–A <br /> PHONE W/APEA CODEITYPE OF BUSINESS OTHER 0?(N <br /> ( ) 01 GASOLINE STATION 't 'k <br /> NUMBER OF CONTAINERS PUPAL AREAS ONLY T: JT�OWNSHIP RANGE -SECTION <br /> 111 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> F� . <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (_\,C"l TAW 04 OTHER- CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (>4- UNKNOWN <br /> D. CONTAINER CAPACITY: CCCV GALLONSL( ) UNKNOWN E. DOES THE CONTAINER STORE: 01 WASTE (X 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? C^l 01 YES 02 NO IF YES CHECK APPROPRIATE BOX(EF,)- <br /> 01 UNLEADED 02 REGULAR 03 PREMIUM 04 DIESEL 05 WASTE OIL V) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM (AtMNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) LkY-02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 01 DOUBLE WALLED (>�f 02 SINGLE WALLED 03 LINED <br /> D. 0401 CARBON STEEL o? STAINLESS STEEL 03 FIBERGLASS 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> ) 06 ALUMINUM 07 STEEL CLAD 08 BRONZE 09 COMPOSITE 10 NON-METALLIC <br /> 12 UNKNOWN 13 OTHER <br /> PAGE I <br /> KSC04-070185 <br />