Laserfiche WebLink
I OWNER <br />NAM!(COPPORATION.INOIVIDUAI OR FU®LEC AGENCY) <br />STP!ET ACORESS <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />( ! 01 FED ( ) 02 STATE ( 1 03 LOCAL <br />FACILITY NAME <br />---- <br />v <br />13 <br />DEALER/FOPEMEN/SVPEPVISOP <br />-- — <br />STPEET ACC°ESS <br />STATE ID NUMBER <br />APPLICATION FOR PERMIT TO <br />OPERATE UNDERGROUND <br />STORAGE TANK <br />I&f 01 <br />NEW PERMIT ( 1 05 RENEWED PERMIT <br />( 1 07 TANK CLOSED <br />( D 09 OELETE•FROM FILE (NO FEE) <br />( ) 02 <br />CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT <br />( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAM!(COPPORATION.INOIVIDUAI OR FU®LEC AGENCY) <br />STP!ET ACORESS <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />( ! 01 FED ( ) 02 STATE ( 1 03 LOCAL <br />FACILITY NAME <br />---- <br />rcej, <br />13 <br />DEALER/FOPEMEN/SVPEPVISOP <br />-- — <br />STPEET ACC°ESS <br />NEAREST <br />CROSS STPEET <br />CITY <br />COUNTY <br />IIP <br />MAILING ADDPESS <br />CITY <br />STATE <br />ZIP <br />PHONE W%AVEA CODE <br />- - <br />TYPE OF ®USIN!SS <br />) 01 GASOLINE <br />STATION ( <br />1 02 OTHER <br />NurtiER CF M NTAINEPS <br />1" UPAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />�OAYS: NAME(LAST NAME FIPST) AND PHONE W/APER 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 A. <br />(A 01 TANK (-D 02 OTHER: <br />B. MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG <br />CONTAINER NUMBER <br />C. YEAR INSTALLED 6 ( D UNKNOWN <br />0. CONTAINER CAPACITY: - GALLONS ( I UNKNOWN E. GOES THE CONTAINER STORE ( 1 01 HASTE (V) 02 PRODUCT <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? P 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />I ) 01 LRILEADED ( I 02 REGULAR ( ) 03 PREMIUM l ) 04 DIESEL ( ! 05 WASTE OIL QQ 06 OTHER �S,/ <br />V CONTAINER CONSTRUCTION <br />A. THICY.NESS OF PP.IMARY CONTAINMENT: ® ( ! GAUGE ( INCHES ( 1 CM l )UW NOWN <br />B. ( 1 01 VAULTED (LOCATED IN AN UNOERGROUNO VAULT) ! ) 02 NON -VAULTED ( ) 03 UNKNOWN <br />IC. ( i 01 DOUBLE WALLED ( 02 SINGLE WALLED 1 1 03 LINED <br />D. (14. <br />01 CARBON STEEL 1 ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />t 1 06 ALUMINUM 1 ) 07 STEEL CLAD ( 1 08 BRONZE 1 ) 09 COMPOSITE ( ) 10 NON-METALLIC <br />t 1 12 UNKNOWN ( ) 13 OTHER: <br />HSC04-070185 PAGE 1 <br />