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071/11/02 THU 14:12 FAX 209 933 6909 COUNTRY—MARKETPLACE 0 002 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page Iw Silo) <br /> TYPE OF ACTION r 1.NEW SUE PERMIT r 2.RENEWAL PERMIT r S.CHANGE OF INFORMATION(Sper4ychsms- r T.PERMANENTLY CLOSED SUE <br /> hec <br /> (Ck ene nem 0* r 4 AMENDED PERMR p vwyy) r B.TANK REMOVED 400 <br /> EM <br /> r 8.TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION - <br /> BUSINESSNAME(Semc as FACILITY NAME or D9A•Dekq Busircss As) 9 FACILITY ID <br /> 4� <br /> iI� �14 <br /> NFAtIS91 CRO STREET 401 FA�CIIILRYONMER TYPE r 4. LOCN.AGENCYIDISTRICT' <br /> r)(CDRPORATION r 5. COUNTYAGENCY• <br /> BUSINESS TYPE ry(L GAS STATION r 3.FARM 5.COMMERCIAL r 2. INDNIDVA- r 6. 6TATE AGENCY' <br /> r 2.DISTRIBUTOR r a,PROCESSOR 6,0 40 <br /> IK(s. PMTNFASHIP r T. FEDERALAGENCY- 402 <br /> 409 <br /> TOTALNUMBEROFTANKS Is fwW an Ltdw R4urv81iona 'N Owner at UST a s"Ie egwl name Neupervkerm <br /> REMWNBrG AT SUE17({4 <br /> IrvzLLvMs? R:' (OTNhN'na Vie comae perev0 fm"IwAiemrEe <br /> 404 r Yes 9 405 405 <br /> II-PROPERTY OWNER INFORMATION <br /> PROPERTY OWNERNAME 40T HONE <br /> SuKmq-�labaz S - Glu 09)4,33 -Il y <br /> MNLING OR STREET ADURE55 409 <br /> w . <br /> CITY 410 A E 411 LPC E 412. <br /> CA <br /> PROPERTY OWNER TYPE r 2 INDMDUAL r 4.LOCAL AGENCY/DISTRICT r B. STATE AGENCY 413 <br /> r CORPORATION F3. PARTNEnHIP F S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III-TANK OWNER INFORMATION <br /> (} (� �,••, /]y r�/�Q,�,��•q PHONNE _415 <br /> TANK OYyJER WN1`-' 4'S 2 � c D Os'1 W iC J 1 x lr 1p..[�LI <br /> MNLINGS;R]ISTREET A➢ORESSW 418 <br /> CRY <br /> ATE 41tl MF E 419 <br /> 41] ` CA <br /> SYo SON �r7 1 <br /> TANK OWNER TYPE �� r 7. WDMDUAL r 4. LOCAL AGENCY!DISTRICT r 6. STATE AGENCY 420 <br /> r kk/CORPORATION r 3. PARTNERSHIP r 6.COUNTY AGENCY r 7. FEDEAALAGENCY <br /> GFPF.=ACQOIlWr RIM... <br /> TY(TK)HO 4 4 - Call(916)322-9669 if Que5tions arise 421 <br /> INDIWTE METH0015)-Ft SELF-INSURED r 4.SURETY BONG r 7. STATE FUND r 10. LOCAL GTN=T MECHANISM <br /> F 2 UARANTEE r 5. LETTER OF CREDIT r fl STATE FUND&CFO LETTER r 89. OTHER 4R1 <br /> r �I INSURANCE r 6 EKEMP710N r 9. STATE FUND S CD <br /> dledr erM aMlW YkidewNkO etltlloes sMupW KeB ler Ngelm raBoOs s.d msMO_ 1. FACILITY r 2 PROPERTYCWNER r 3.TANKOWNER AM <br /> L nms aM e' x wie Be erk kss 2 a <br /> CeNflAIYlT. I bat Ne Mro�mauon A90 conn a Wa AM emN1Y M em BeM eRMY keewbeRe. <br /> SIGNATV Mr. DATE 11� I�y I 424 tNO <br /> Q 1 q 21 IYyp� 425 <br /> NE <br /> xAME OF APPLICANT( 426 T F APPLICANT 427 1 J J-• 10 <br /> u"��e lam s . G 11-1--• �. Irl�� <br /> 'STATE UST FACILRY NUMBER(Fmbcel usa erdY) 428 19eB UPGRADE CERTIFN;ATE NUMBER(Fwbc4l ur omy) 429 <br /> 5 <br /> UPCF(1199 ravLRed) Formerly SWRCEl Form A <br />