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STATE -0 NUMBER <br /> 4 i3 � <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE <br /> f 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> lei 02 CONDITIONAL PERMIT ( 106 AMENDED PERMIT ( ) OQ MINOR CHANGE (NO SURCHARGE) F ER[ i /SERVICES <br /> I OWNER <br /> NAME(COPPORA ION.I NDIVIDUAL R PUBLIC OE Y) PUBLIC AGENCY ONLY <br /> ( 1 <br /> 01 FED 1 1 02 STATE l ) 03 LOCAL <br /> $ <br /> TR3fT ACCRESS (_ C 1J�wA STAT P 3 Le <br /> Z - 449 sJ7 <br /> II FACILITY <br /> FACILITY E 0EALfjF{FOR MEN/S PFJ WI O <br /> o'U <br /> STREET AOOPESS NEARES CR S STREET) <br /> /lox- a�.k� �. <br /> CITY `-s C / COVNT CJ Y� Z2P <br /> VJ`.(�/-w� L o <br /> M42L 111 U FESS - C TYC.n n -_ STATE ZIP <br /> NG CCY_. <br /> PHON• APfa CODE TYPE OF BUSINESS <br /> L b K) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUCBEP 06 CONTAINERS PUPAL AREAS ONLY TOWNSHIP PANGS SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> 0AY NAY, LAST N ME FIRST) ANO PHONE W/AR 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. ("l O1 TANK ( 1 02 OTHER: CONTAINER NUMBER (7 <br /> B. MANUFACTURER (IF APPROPRIATE): - �6 YEAR MFG: C. YEAR INSTALLS d ( l UNKNOWN <br /> .. NTAINER CAPACITY:S_zb GALLONS l 1 UNKNOWN E. DOES THE CONTAINER STORE: RC1 01 WASTE A ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? *A) 01 YES ( l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 1 ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM l ) 04 DIESEL W 00 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( I GAUGE f l INCHES ( ) CM 1/- 1 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED Y'Y 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAD f ) 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> . 12 UNKNOWN f l 13 OTHER: <br /> HSC04-07?185 PAGE 1 <br />