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06/07/2004 08:53 2094683433 FIFTH FLOOR J-) PAGE 013 <br /> A`QMUD PROGRAM COON 0LEDT=Fk,,,oM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FAC I <br /> (One c per site) Page of <br /> TYPE OF�ACT20:N <br /> I.NEW PERMIT El 3.RENEWAL PERMIT 13 5,CHANGE OF INFORMATION [17-PERMANENTLY CLOSED <br /> TYPE <br /> ;one item only) C1 4.AMENDED PERMIT (Specify change) SITE 400. <br /> ❑6 TEMPORARY SITE CLOSURE TANK REMOVED <br /> i 7 <br /> L"'FAC <br /> . .......... <br /> S N <br /> (gone as FActurry NAme or DBA-3)0'v#Ruil"Cal All) 3. FACILITY <br /> IDA <br /> NE 0T SS STREET 01. FACILITY OWNER NtA I r FE 4.LOCAL AGENCY/DISTRICT' 4OZ S . /W- <br /> Ll I. CORPORATION 1:15-COUNTY AGENCY- <br /> bUSINIESS 1.GAS STATION 03=FARM 05COMMEP-CIAL 40, D 2 )NDIVIDUAl. E]6.STATE AGENCY0 <br /> TYPE El 2.DISTRIBUTOR Ll 4-PROCESSLp ()6-_ 0 1 PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF Is facility on Indian <br /> Reservation <br /> dos 406. <br /> REMAINING AT SITE or trust lands? larilellwhich ol)(22testhe UST, (This is the enamel person Corihc rank recortU.) <br /> [J Yea No sad <br /> II ROM WN <br /> NVNE <br /> Prj, RTY 0 R3 407, <br /> MmWM ORS71 <br /> WET ADDR2 4M. <br /> _11'mL61 VlGrff <br /> 4 <br /> CTP AM <br /> STAT411. [ JTJ_7 <br /> 412. <br /> PROPERTY OWNER TYPE 1.CORPORATIONLl 2.INDIVIDUAL 4,LOCAL AGENCY I DISTRICT LJ 6.STATE AGENCY 413. <br /> 03,PARTNERSHIP El 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> ... .... ...... <br /> TANK OWNER NA7 ....... <br /> (I'1 0 414, 413, <br /> MAILING OWSTREET ADDRESS 416. <br /> CITY r 17. STATE 418. ZWOP <br /> CE 419. <br /> CITY <br /> ,_v <br /> A <br /> TANK OWNER TYPE El I CORPORATION Lj Z.INDIVIDUAL4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY eza <br /> ❑3.PARTNERSHIP <br /> e<_ 1 <br /> 5-COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> T <br /> TY(TK)HQ 44- Call(916)322-9669 if questiow arise 421, <br /> INDICATE METTIOD(S) 0).SELF-INSURED 0 4.,qURM7Y BOND 117.STATE FUND 10.LOCAL GOVT MECHANISM Qj <br /> El 2.GUARANIES 0 S.LETTER OF CRMIT [3 9.STATE FUND&CFO LETTER L]99.OTHER: <br /> 0 3-INSURANCE 0 6.EXEMPTION L3 9.STATE FUND&CD <br /> VI LEGAL I�OTIR�Gi1T N ANI) <br /> Check one box m 11--which addross should be u9ed 1br leppl tionficapons and mailing. <br /> [.gal notificadons and mailings Mll be unt tc,the milk owiim unlies,ban I or 2 is checked 0 1.FACILITY F2. PROPERTY OWNER 0 3.TANK OWNER 423. <br /> Certification: I certify that the iniblIfflitift provided lacicin is true and accurate to the best of my knowledge. <br /> SIGNATURE 01�APPLICANT DATE AIA. pHONE <br /> yy\oz� / ( C,� <br /> .V�2 - <br /> NAME OFAYrLIL;ANI-jprint) 426. TITLE OF APPLICANT 427, <br /> STATE USTFACILITYINUMBER(Aanwy...iy) 428 1998 UPGRADE CERTIFICATE NUMBER(As--y-only) 429. <br /> (3ft Dam Elcn=t 1,above. <br /> UPCF (1/99)-1/2hrtp:/{www.UnidocsorgRev.02/16A0 <br />