CITY OF FREEPORT
LICENSE APPLICATION – SELF-SERVICE GASOLINE STATION
TO: Fire Inspector
City Clerk’s Office
314 West Stephenson Street, Suite 200
Freeport IL 61032-4327
Annual Fee Due by December 31 of each year………………..……….…………$250.00
THE UNDERSIGNED HEREBY MAKES APPLICATION FOR A LICENSE TO OPERATE A BUSINESS AT:
Address: , Freeport, Illinois.
Station Name: Operator
Bureau of Fire Prevention Faculty # (refer to State License)
I, the undersigned, thoroughly understand that this is solely an application and is not permission to open an establishment or operate a business until all applicable requirements of Chapter 862 of the Codified Ordinances of Freeport, Illinois, have been fully complied with and approved by this department for issuance of an official license by the City of Freeport.
Corporation Name
Corporation Address
President
Vice President
Treasurer
Responsible Agent
Total Number of Pumps Full Self-Service Station? Yes or No
Number of Pumps Dispensing Self-Service
Total Number of Islands
I hereby agree to comply with the requirements of the Codified Ordinances of Freeport, Illinois, Chapter 862 Self-Service Gasoline Stations and those of the International Fire Code.
Signed Date
Resident Address
Phone Number
The foregoing application is (circle one): APPROVED REJECTED
Date
, Chief Fire Inspector
Permit Issued City Clerk