Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM [� <br /> llw' <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page I of i <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT F/5.CHANGE OF INFORMATION(SPedly charge- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r <br /> 4.AMENDED PERMIT local use Prly) r 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> PN�kEST <br /> Same as FACILITY NAME w OBA-Going Business Aa 3 FACILITY 10 i <br /> , ` L FAQ ITY OWNER TYPE r 4. LOCAL AG'cNCYIDISTRICT' <br /> STREET 401 V s�0 [s/1. CORPORATION, � r 5. COUNTYAGENCY• <br /> [' t.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. 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 /> TOTAL NUMBER OF TANKS Is faoliry on I1ldian fteservaaron Pt 'di owner of UST is a ti-agenq:name of suoemsar of <br /> REMAINING AT SITE I r .S IruiaaMs9 (i .is se wm w pairs wmcn a tars,a U w UST. <br /> %( (This is Na motel person for the Iank recaras.) <br /> q04 U) Aµ J r Yes YNo 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PHONE 4DB <br /> 0 - <br /> PROPERTY ONMER NAME 407 <br /> #7RNr � <br /> MAILING OR STREET AOOES�Ss 409 , 1 <br /> I ` e-)- C STATE 411 ZIP 00 4t2 <br /> ;;rr =:D <br /> �o G 6r ? S-906 <br /> PROPERTY OWNERTYPE r 2. INDIVIDUAL r a. LOCAL AGENCY'DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3 PARTNERSHIP r 5 COUNTY AGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> TANK OWNERNAME 414 <br /> � � : 2� 71 70C MAILING OR STREET ADDRESS 416 <br /> Gv - C v'� ell <br /> 12 STATE^ +18 ZIP CODE 49 <br /> EO"ER-PE <br /> C <br /> r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATEAGENCY 420 <br /> r./j. CORPORATION r 3 PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> AT[ Arrr)ljNTNIIMFU7P <br /> � <br /> TY(TK)HO 4 4 - � K /"i ({ 11 -UW/c Alr! K�„)(916)322-9669 it questions arise J 7 tj q _ �G,� M 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r2. GUARANTEE r 5. LETTER OF CREDIT E-�8. STATE FUND&CFO LETTER r 99. OTHER: <br /> ,/ 422V 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD <br /> Ch bo10 TIC- hich adoral.V.w lin9, 1✓1' FACILITY 1 2. PROPERTYOWNER r J. TANKOWNER 423 <br /> R M melmQ5 willD to thk b 2 d <br /> Candlcation: I candy Mat Ne mformation provkleB harem is true arw accurala to Ne best of my Imoxleoge. <br /> GATE 42aPHONE O _ , 425 <br /> SIGNATURE OF APPLICANT d,� <br /> NAME OF APPLICANT(onnt) 425 TITLE OF APPLICANT 427 <br /> cd v vswii- <br /> STATE UST FACILITY NUMBER(Fork l use omy) 428 1998 UPGRADE CERTIFICATE NUMBER(Fw local use only) 429 <br /> limpd `4111110 <br />