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'1 V -'FIED PROGRAM CONSOLIOATEO CORM <br /> ../ HEC tf '`JED TANKS <br /> UNDERGROUND STORAGE TANKS — FACILITY <br /> APR 0 o 2002 :Orta OagepeYsrte) <br /> I. OF AC TION [' L Nc W SITE PERMr F 1.RENEWAL PERMIT _ANGE OF INFOftMAT:CN iSPee.2psp.gt}LII JIV1i.xi�ekfiMN `T�kk CS'.O SITE <br /> (G;xA ane item amyl x us .M ? <br /> F +AMENDED PERMIT I-r . -EIAPORARY SITE CLOSURE <br /> L FACILITY I SITE INFORMATION <br /> 3u5:NE55 NAME l5ame asfl.GIITY. w DBA-CEuq Bufnasa Ail 3 AC:uTY. io s <br /> 5 K s e- -it's L b6R GoL7►7Tf2Y K1APy P/Hce (�I l <br /> i N ST GROSS STREET 41 FAC:UTY OWNER TYPE r n, LOCALAGENCYICIS�, ICT- <br /> �1e`1o <br /> _ CyI C,^,RPORATION <br /> or S. COUNTYAGENCY• <br /> BUSINESS TYPE r 1 SAS STATION r 3.FARM r S.COMMERCIAL r 2 :NONIOUAL I r"B, STATE AGENCY- <br /> r 2 DISTRIBUTOR r +.PROCESSOR r d.OTHER F 1. PARTNERSHIP T- T. FEOERAL AGENCY' -02 <br /> +Ol I <br /> TpTAL NUMBER OF TANK$AFMs:aeury an vam+ReswYscan w -tt a..ner w UST's a ZdIC agener name er usT. war <br /> OTA.NUMATSITE auwrm? arvuKul,xea^w'afir'^nim 0oenly:+`s UST. <br /> / (TILLS u me GntaG'+RSfl„Dor A.•dn✓.r4'tCi) <br /> r Y � . +OS +O6 <br /> H.PROPERTY OWNER INFORMATION I <br /> P0.0PE0.TY 0WE0.NAME OT G � G /CL-su6(�� s . ( u, PGHX-O'svNE�7+ +008 <br /> om^ JJ <br /> O�r <br /> TREETADu.... , <br /> — <br /> 17�9 STA/,E� 71P COO <br /> Y+,2 / <br /> C: n0 I LJI I -120 b <br /> Sf�GK i Aj <br /> PROPERTY OWNER TYPE r�2 �NOIVIOUAL F +. IOCALAGi.4CYf OISTRIQ F i. STA�cAGENC +13 <br /> ri. CORPORATION ( 2 PARTNERSHIP C i. COUNTYAGENCY F T PEOEPALAGENCY <br /> III-TANK OWNER INFORMATION <br /> f^Ut-3T J Aef l PHONE +15 <br /> TAIK OWNER NAME ns t.CJ I �R. <br /> Stt � SP i rJ �. J��Iti PL P'cE lao9 C133- (&9 <br /> MAIU�INGG OR STREET AOR ^y,y6/�i_(���•••}/�3 <br /> 1 199• ' "• �H `( "" Wr4tl I STATE -18 I ZIP COO +t5 <br /> CDrr +n CA I gSao 6 <br /> - OWNER <br /> S VL,Pc o"1'-',( r 2 :NDNIOUAL r +. LOCALAGaNCYIMS�- ICT r i. iTATEAGENCY +20 <br /> •✓'. CORPORA1lON r 3. PARTNERSHIP F S. COUNT-AGENCY r '. FEDERALAGENCY <br /> cR- <br /> ! TK)HO 4 4 <br /> V I I I Call(4161 S2Z-°fi69 if 7uesti0ns apse `' <br /> J OC-fR(ll DIM IIGTF <br /> INDICATE METHOO(S) [' t. SELF+95URED r +. SURETY BOND F T. sTAT.FUND r0 COAL GOV-T MECHANISM <br /> los <br /> M _ <br /> r 2 GUARANTEE r S. '��ER OF CREDIT F 3. STATE FUND d CFO L l-Ai r 33. OTHER At--' C3 +22 <br /> r 3. INSURANCE F S. EXEMPTION r 3. STATE FUNO S CO <br /> IC C <br /> C cOr pelmG` V9a bfic ti^14 V -ACIUTY r ' 'FCPER"'CWNER r I TANK OWNER +23 <br /> . aI nobficacov an0 marlines will be sem.a b eQ <br /> , R <br /> Can18n11Pn' cents Nat Ne rcM tion crwceR Heren n we ara RIs m tn.best of MY wv ware. +25 <br /> SIGNATURE OF ( <br /> APPLICANT ]ATE �p D �� +2+ .21 <br /> O nel J J <br /> NAMECf PLICANT( rl +251 T fAPPU�A T +2T <br /> rl GILL I IlJ <br /> STARE UST FACILITY NUMSER(Fw:od use a•ai'I +2SI 'ia UPGRADE CERTIFICATE nUMBER lPw+aa xse oNYl +29 <br /> I j <br /> ij <br /> 1 <br />