Laserfiche WebLink
STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 09 DELETE FROM FILE (NO FEE) <br /> I NEW PERMIT 0 RE E PER 07 TANK CLOSED 5 '4 W:1) <br /> W - �,o� PERMIT )8 MINOR CHANGE 0 SURCHARGE <br /> 02 CONDITIONAL PERMIT 06 AMENDED <br /> E <br /> Fi>f <br /> I OONE R <br /> NAME(COPPORATION,INDIViDUAL OR PUBLPUBLIC AGENCY ONLYTc AGENCY) 0<1-01 FED 02 STATE 1 03 LOCAL <br /> IT, <br /> ZIP <br /> CITY STATE STREET I <br /> !�ADPT'C <br /> FACILITY <br /> �FACIL TY NAME - DEALER/FOREMAN/SUPERVISOR <br /> STREP " REBS <br /> NEARESX CROSS STREET <br /> CESS <br /> 4) <br /> jo-J, <br /> CITY I <br /> COUNTY-, ZIP <br /> t_Ck�_Kf�q It <br /> CITY STATE ZIP <br /> MAILI ADPRESS F <br /> � <br /> ye La k rop <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION ()40 OZ OTHER l"ia r <br /> R SE <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE <br /> CTION <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 /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. *f 01 TAW 04 OTHER: CONTAINER NUMBER 66- 61-IL <br /> B. MANUFACTURER (IF APPROPRIATE)'. YEAR MFG: C. YEAR INSTALLED D<TUwmowN <br /> 0. CONTAINER CAPACITY: /13-S--GALLONS UNKNOWN E. DOES THE CONTAINER STORE: 01 WASTE (>4-02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL 01 YES 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 01 UNLEADED 02 REGULAR 03 PREMIUM (AT 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) (0'02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 01 DOUBLE WALLED (Aj'f 02 SINGLE WALLED 03 LINED <br /> 01 CARBON STEEL 02 STAINLESS STEEL 03 FIBERGLASS 04 POLYVINYL CHLORIDE 05 CONCRETE <br /> )l 09 COMPOSITE 10 NON-METALLIC <br /> ff(( ):06 ALUMINUM 07 STEEL CLAD 08 BRONZE <br /> 12 �: <br /> 12 UNKNOWN 13 OTHER* <br /> PAGE I <br /> HSC04-070185 <br />