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APPLICATI_ _-ON FOR PERMIT TO OPERATE UNDERGROUND STATE ID NUMBER <br /> �1�01 NEW PERMIT f 1 OS RENEWED PERMIT <br /> ( 1 02 CONDITIONAL PERMIT STORAGE TANK <br /> ( 1 06 AMENDED PERMIT ( 7 07 TANK CLOSED <br /> —�� f ) 08 MINOR CHANGE (NO SURCHARGE)) 09 DELETE FROM FILE (NO FEET <br /> I 0PINE R <br /> NAME(COPPOPA ION,INOIVIGUA R PUBLIC_ AGENCY) <br /> Q 5" PUBITC AGENCY ONLY <br /> $7 ET ADDRESS r( <br /> /I/1 CITY 1/ 1 L ( ) O1 FED ( 102 STATE Nk O3 LOCAL <br /> �L_ � - <br /> J I <br /> FACILITY STAT LIP I� 7' <br /> FA' C TY NA �- <br /> a f1 , <br /> DEALER/FOR <br /> ST DRESS (� / \ I1 a EMA N/SVPE RVISOR <br /> //D CROSS` NEAREST ` ' <br /> `q EEi <br /> Cl Y <br /> i <br /> CO <br /> MAILING ADDRESS -------� O ZIP <br /> / CITY <br /> PHONE W/AREA CODE STATE ZIP <br /> Qo �(]_ TYPE OF BUSINESS 9S-3 <br /> � .J ( ) 01 GASOLINE STATION ( /- ._ \/ / <br /> NUMBER OF C TAINERS 02 OTHER �a1 <br /> PUPAL AREAS ONLY TOWNSH75 <br /> RANGE <br /> SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY . NAME(LAST PAME FIRST) AND PHONE W/AREA CODE <br /> C _ NIG S: NAMEIIAST NAME FIRST) AND PHONE W/AR-cA CODE <br /> 0 3 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER 3—� <br /> IV DESCRIPTION <br /> A. (3Cf 01 TANK f l 04 OTHER: <br /> CON AINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLED <br /> /9Gsi, ) UNKNOWN <br /> D. CONTAINER CAPACITY: Q� GALLONS ( ) UNKNOWN E. DOESTHE ONSTORE: t 1 01 WASTE <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ��2 PRODUCT <br /> ( 1 <br /> 01 UNLEADED (�i02 REGULAR ( ) 03 PREMIUM ( ) 04 DIE'7EL 0f 7E05 WASTE 20IL fI) 06SOTHERK APPROPRIATE BOK(ES): <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( 1 INCHES ( ) CM Qct UNKNOWN <br /> B• ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) X-3 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 00 02 SINGLE WALLED ( ) 03 LINED <br /> D. f 7 01 CARBON STEEL ( ) 02 STAINLESS STEEL t ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> ) 06 ALUMINUM ( ) 07 STEEL CLAD f 1 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> VNI 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070165 <br /> PAGE 1 <br />