Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> rx1o1 ( ) 09 DELETE FROM FILE (NO FEE) <br /> NEW PERMIT 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> 02 CONDITIONAL PERMIT 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> OPINE R <br /> PUBLIC AGENCY ONLY <br /> NAME(COPPOPATION,INDIVIOVIO,L OR PUBLIC AGENCY) I (-,-�K-01 FED 02 STATE 03 LOCAL <br /> zIP <br /> D E S <br /> 77 e- CITY STAT <br /> — <br /> 15 K- <br /> STRE Vn AD <br /> _ <br /> II FACILITY <br /> FACILITY NAME 7 DEALER/FOREMAN/SUPERVISOR --- <br /> ry <br /> NEAREST CROSS STQJEET <br /> STREET S <br /> COON ZIP N ZIP <br /> CITY' 9-5-3-5/ <br /> o, <br /> CITY STE ZIP <br /> MAI 'G KESS <br /> PHONE W/APEA CODE I-yp-) OF BUSINESS E Pit I,,4y- <br /> I' - 01 GASOLINE STATION (,r) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL 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 /> A. O<f-0-1 TAW 04 OTHER: CONTAINER NUMBER <br /> ALA CONTAINER NUMBER <br /> ol T <br /> MFG C. YEAR INSTALLED MANUFACTURER <br /> DOES THE CO <br /> �7 YEAR MFG: C. YEAR INSTALLED C14-UNKNOWN <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> 01 WASTE (,1.4�2 PRODUCT <br /> D. CONTAINER CAPACITY: UNKNOWN E. DOES THE CONTAINER STORE: <br /> -1-1 YES 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> S TH <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL (NO 05 WASTE OIL 06 OTHER <br /> UNLEADED <br /> NLEADED 02 REGULAR 03 PREMIUM 04 DIESEL <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: GAUGE INCHES ( ) CM ()vYUNKNOWN <br /> B. 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 5,4-02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 01 DOUBLE WALLED L>0-02 SINGLE WALLED 03 LINED <br /> PAGE 1 <br /> HSC04®070185 <br />