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06/07/2004 08:53 2094683433 FIFTH FLOOR PAGE 03 <br /> `,..DIED PROGRAM CONSOLIDATED FlizeAl <br /> TANKS � <br /> UNDERGROUND STORAGE TANKS ]FACILITY lc� <br /> (one page per site) Ile <br /> TYPE OF ACTION 0 1 NEW PERMIT 0 3.RENEWAL PERMIT 13 5.CHANGE OF INFORMATION 0 7-PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [34,AMEND=PERMIT (SScci�v change) TANK"MOVED <br /> C1 6.TEMPORARY UM CLOSURE <br /> FAC <br /> BU SS NAME <br /> el�CaM NAME orDSA-Win 11ala,,M) <br /> N CR S STREET 401. FACILITY 0 I ER TYPE >V,LOCA TRICT. 92, <br /> EF-3 1.CORPORATION []5.COUNTY AGENCY- <br /> 1.GAS STATION [j 3.FARM 403. Lj 2.INDIVIDUAL [3 6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4-PROCESSOR 6-_0 113.PARTNERSHIP [17.FEDERAL AGENCY- <br /> TOTAL NUMBER OF TANKS Lu <br /> Is ,l,ry u dish <br /> on 405. *If 0wae:of UST is a public opmacy;Dame of supervisor <br /> REMAINING A E or this[]ands? oEdivisionsecdonor 106. <br /> 011Iec which 01)(23142 the UST. (Thin is the cffllmct�lbribc tank records.) <br /> 0 Yet; PrNo <br /> lI q p, ......... <br /> RD 1p - <br /> VM It,-NF ........ ......... <br /> Rolr <br /> PRO 7Y 0WNr AME Oar PH <br /> QNE <br /> 1`43kI%66 <br /> R, T DRAS <br /> 409. <br /> Cn 4W, STA' ZIP COD 7&�5g 412. <br /> ev <br /> PROPERTY OWIVER TYPE Lj 1.CORPORATION 2.INDIVIDUAL X4.h A 4 <br /> LV1,.LOCAL71� AGENCY I DISTRICT L1 6-STATE AGENCY 43. <br /> 01PARTNERSHIP El 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> ............... <br /> III TANK <br /> TAnO <br /> �WNAM 414, PRONE. . <br /> 41U, <br /> MMUNq EIR S T ADDRE 41 . <br /> "EU M26 wo <br /> Cfry_,,�,G LAIJ 417. STATE P A as. ZIP CODE 419. <br /> t-j,-7 20 <br /> TAM OWNER TWE El 1.CORPORATION El 2.INDIVIDUAL .LOCAL AGFNCYIDTSnUCT Lj 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> i <br /> 0 ZA . <br /> MON.)v <br /> Call(916)322-9669 if questions arise 421. <br /> 1,111 ..... <br /> INDICATE METHOD(s) 0 1.SELF-INSURED [14.SURETY BOND 117 STATE FUND D 10.LOCAL Gorr MECHANISM <br /> LI 2.GUARANTEE [3 5.LETTER OF CREDIT C1 9.STATE FUND&CFO LETTER [3 99.OTHER! <br /> D 1.INSURANCE 0 6.EXEMPTION 0 P.STATE FUND&CID <br /> LEGAV <br /> Check me box-mencatc winch adhimn should be Lnec!tor lop]notification and mailing. <br /> Legal milicadons and mailings will be Sam 10 the Walk 0-c,MIMS box I or 2 is checked ❑ ].FACILITY 2. PROPERTY OWNER [13.TANKOWNER 422. <br /> 3 .1 <br /> AJIMCAN' WN <br /> Certification: I certify]hat the inibronaLion mvvidcd herein is true and acce,aft to lbebal ninny knowledge. <br /> SIG PL T DATE d24 PHONE 423. <br /> 9 833- <br /> N AP <br /> PLICA TITLE OF APPLICANT <br /> STATE UST FACILITY NUMBER(A$.7...ly) 428. 1998 UPGRADE CERTIFICATE NUMBER(AAr 429. <br /> (See Dam Element 1,above. <br /> UPCF Bwfwro-z 0/99)-112 Rev.02n6/00 <br />