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UNWED PROGRAM CONSOLIDATED f �tMIZIt/aY )e3 <br /> _ !2;/0e-/ TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY,/5?-?- :yr �p� ��• <br /> 3.•� as (��ba4e�Pe7"site) <br /> Page _ of _ <br /> TYPE ACTION NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(SPeGlyc .Ve- r 7.PERMANENTLY CLOSED SITE <br /> :Acct We <br /> one dem oMy) Y <br /> 4.AMENDED PERMIT Ii use only) ra.TANK REMOVED 400 <br /> I <br /> r�6.TEMPORARY SRE CLOSURE <br /> I.FACILITY!SITE INFORMATION <br /> IUSINESS NAME(Same as FACILITY NAME a DBA•Ookp B"m As) 3 FACILITY IO M <br /> ai - <br /> IFAR�ST 401 _ (V4,CORPORATION <br /> OWNER TYPE r 4. LOCAL AGENCYIDISTRICT' <br /> (V4,CORPORATION r 5. COUNTY AGENCY' <br /> IUSINE S TYPE I' I.GAS STATION r�1 FARM (�COMMERCULL r 7- INDIVIDUAL r 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r� 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402' <br /> 403 <br /> Mal <br /> TOTAL NUMBER OF TANKS u taalay m anFlRlu 'M"w of UST u 39-WY.nIll MW a9aname Of of <br /> REMAINING AT SITE vusaanW7 alw-aeoan or aura"'P'al opentea Ne UST. <br /> 404 / �� (TMs is the mnlart Paean for Ole ullk remlas.) <br /> l// r Y. /941 405 406 <br /> H.PROPERTY OWNER INFORMATION <br /> PHO <br /> PROPERTY OWNER NM1E 407 4� ®�Q <br /> G� T 1rSTG <br /> MAILwc oa ST"FE1ADD E� +� �/• �� nO QO . <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCALAGENCYIDISTRICT r 6. STATE AGENCY 413 <br /> CORPORATION r 3 PARTNERSHIP F 5. COUNTY AGENCY r'7. FEDERAL AGENCY ` <br /> III.TANK OWNER INFORMATION M <br /> PHONE +Q <br /> TANK OWNER NAME 414 5 <br /> C-/ T d9 ST l <br /> MAILING OR STREET ORE S 416 <br /> V�� �� A 416 LP 419 <br /> CITY 417 <br /> . 5-;;10 <br /> TANK,OWNER TYPE r 2. INOMDUAL r 4. LOCAL AGENCY I DISTRICT r- 6. STATEAGENCY 420 <br /> CORPORATIONT ] PARTNERSHIP r S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HQ 4 4 Call(916).322-9669 if questions arise 421 <br /> I <br /> INDICATE METHOD(S) T 1. SELFaNSURED r 4. SURETY POND r 7. STATE FUND r 10. LOCAL GOVT MECHANISM <br /> r 2- GUARANTEE r S. LETTER OF CREDIT r a. STATE FUND i CFO LETTER r 99. OTHER 472 <br /> 2 INSURANCE r'B. mmPnON r 9. STATE FUND&CD <br /> CMG lI a I w as aMwaM cal legal tR awl ma,wv. r 1 FACILITY PROPERTY OWNER r 3. TANK OWNER 423 <br /> rgldp tM madma, 611 DC aMI I ale I k lro tlleG <br /> ecl <br /> Cerwi=b n 1 Cally Wt Ne vlfannatkln PIo'^ab nenM P Wa ell aateAata to Use oast M my knowladg.. - 424 PHONE 937 / 425 <br /> SIGNATURE OF APPLICANT DATE <br /> �_ 425 TITL'c 427 �O, <br /> NAME OF APPLICANT(pnnt) <br /> STATE UST FACILITY NUMBER(Fo kxaI ase 0MY) 428 1998 UPGRADE CERTIFIUTE NUMBER(Farpcal use oNy) 429 <br />