Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (1-4O1 NEW PERMIT t 1 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 /> AGENCY <br /> NAME(COPPORATION,INDIVID AL OR PUBLIC AG Y) PUBLIC AGENCY ONLY <br /> x+_01 FED 02 STATE 03 LOCAL <br /> CITY1 STATE ZIP <br /> _STRE RE�l <br /> II <br /> FACILITY <br /> DEALER/FOREMAN/SUPERVISOR <br /> FAC5Y NAME <br /> r <br /> STRE ADD� NEARES;[ CROSS STRET <br /> COUNTY <br /> —lzp , <br /> CITY <br /> 3 3 L <br /> MAI J <br /> 3 A CITY �_CL STATE ZIP, z <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION 02 OTHER <br /> NUMBER OF CONTAINERS a PUPAL AREAS ONLY . TOWNSHIP RANGE SECTION <br /> 111 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> CONTAINER ER <br /> CONTAINER <br /> C. YEAR INSTALLED <br /> A. 0�,,l 01 TANK 04 OTHER: CONTAINER NUMBER 6-3-5--4 <br /> Lo <br /> B. MANUFACTURER (IF APPROPRIATE)'. YEAR MFG: C. YEAR INSTALLED 0-st UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS UNKNOWN E. DOES THE CONTAINER STORE: 01 WASTE ()0-02 PRODUCT <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 P4T-04 DIESEL 05 WASTE OIL 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE INCHES ( ) CM UNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Dry 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ol DOUBLE WALLED L;,4 02 SINGLE WALLED 03 LINED <br /> N H 05 CONCRETE <br /> D.ffud01 CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS 04 POLYVINYL CHLORIDE <br /> 0 0 0" � ( ) 09 COMPOSITE 10 NON-METALLIC <br /> 6 ALUMINUM 07 STEEL CLAD 08 BRONZE <br /> 1 JL <br /> MoWtj <br /> 2 UNKNOWN 13 OTHER. <br /> PAGE I <br /> HSC04-070185 <br />