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• STATE IO NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />1 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED l 1 09 OELETC FROM FILE (N0 FEE) } <br />02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(COPPORATIO .INDIV <br />t QR FV5LIC AOEtACY ) <br />STREET AOnQZSS <br />_----��' <br />II FACILITY <br />PUBLIC AGENCY ONLY <br />( 1 01 FED 1 ) 02 STATE ( 1 03 LOCAL <br />ITY/ I I TATE <br />cl IZ2P <br />9c <br />FACILITY NAME <br />DEALER/FOPEM NSU%P�ERVISOP a/ T Q <br />STREET ACCESS <br />NEAPEST CROSS STPEET <br />wao� <br />CITY j <br />COUNTYZIP <br />4✓� <br />5�� <br />Q �N <br />- <br />MARI0NO ADDPE <br />CIT <br />STAB <br />ZIP <br />PHONE W%AREA CODE TYPEOf BUSINESS <br />.� 06 01 GASOLINE <br />STATION ( 1 02 OTHER <br />NUMBER CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP PANOE SECTION <br />...s` <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: - (.(2 C fI STI AND PNON� / PPA CODE41-2-1V f NIONTS: NAM �A T NAME FIRST) AND PHONE WIA;E1 <br />12,-7467-1 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />g IA. <br />TANK ( 1 02 OTHER: <br />B. MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />CONTAINER NUMBER <br />C. YEAR INSTALLED 14L,4 ( 1 UNKNOWN <br />0. CONTAINER CAPACITY: GALLONS t 1 UNKNOWN I E. DOES THE CONTAINER STORE: ( 1 01 WASTE t 02 PRODUCT — — <br />F. DOES THE CONTAINERTORE MOTOR VEHICLE FUEL OR WASTE OIL ? (x 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br />1 1 <br />01 UNLEADED (K C* REGULAR ( 1 03 PREMIUM t 1 04 OIESCt" l ) 05 WASTE OIL t 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PP.IMARY CONTAINMENT: ( 1 GAUGE ( INCHES 1 1 CM l 1 UNKNOWN <br />B. ( 1 01 VAULTED ( LOCATED IN AN UNOERGROUNO VAULT) ( ►�Q2..RIU11-VAULTED 1 ) 03 UNKNOWN <br />�C. ( 1 01 DOUBLE WILLED (/0Z WALLED 1 1 03 LINED <br />0. (A_01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br />( ) <br />06 ALUMINUM 1 1 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br />( 1 12 UNKNOWN ( 1 13 OTHER: <br />HSC04-070185 PAGE 1 <br />