Laserfiche WebLink
STATE 10wMe <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 09 DELETE FROM FILE (NO FEE) <br /> 01 NEW PERMIT <br /> GKT 01 NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> 1 02 CONDITIONAL 13ERMIT 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OPINE <br /> PU�BLIC AGENCY ONLY <br /> NAM 5,�PPOP A T�1101N IN�10) 'I DIU�AL OR�PUU I�CAIGENCY ol <br /> ED 0 <br /> 0.4-01 F��2 STATE 03 LOCAL <br /> CITY STAT <br /> II <br /> FACILITY <br /> FACILITY NAME <br /> NEAREST CROSS STREET <br /> ST PESS <br /> 2COUNT <br /> CITY t; zIP <br /> STATE ZIP <br /> CITY <br /> MAILTAG ADDRESS <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 01 GIA50LINE STATION <br /> L AP E AS ON TOWNSHIP <br /> TOWNSHIP RANGE SECTION <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> REA ODE <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A, CONTAINER NUMBER /01 <br /> YEAR MFG: C. YEAR INSTALLED Ov+ LUEYWNOW]N <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> 12 UNKN THE CONTAINER STORE: WASTE 02 PRODUCT <br /> D. CONTAINER CAPACITY: .,OW GALLONS OWN IE. DOES <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (,)<r 01 YES 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 01 UNLEADED 02 REGULAR 03 PREMIUM 04 DIESEL 04-05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM (A4-UNKNOWN <br /> a. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Q-0'02 NON-VAULTED ( ) 03 UNKNOWNC. ol DOUBLE WALLED G316 02 SINGLE WALLED 03 LINED JE <br /> D. (A�f 01 CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> F T( ) 06 ALUMINUM 07 STEEL CLAD 08 BRONZE 09 COMPOSITE 10 NON-METALLIC <br /> 12 UNKNOWN 13 OTHER: <br /> PAGE 1 <br /> � xsc04-070185 <br />� <br />� <br />