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UN <br /> IFIW rROGRAM CONSOLIDATED F00RN1�' <br /> UNDERGROUND STORAGE TANK 1204.. <br /> OPERATING PERMff APPLICATION—FACILITY INFORMATIONIOwfwn pui <br /> I <br /> O ?-pERM ANuNT FACtLr Y CLOSURE <br /> TYPE OF ACTON ❑ L NEW PERMIT ❑ <br /> 5.CHANGE OF INFORMATION <br /> (Clodasitllaoah') 3.RENEWAL IN <br /> PERIT Q6.TEMPORARY FACILITY CLOSURE C] 9.TRANSFER PERMIT <br /> I. FACILM INFORMATION <br /> TOTAL NUMBER OF LISTS AT FACILITY qp1 FACILITY ID X <br /> d (ggcn Use Only) <br /> BUSR�SNAM6(saersFAOi.ITY xnxt6w OtlA..t)^+^6 t>'n^16���C� Q2u�o Co�3� <br /> CTIY <br /> BUSMFSS SITE ADDRESS IAT <br /> 1,7 W. CA ct� (.14 <br /> 1 FUEL DI6TRIBUTIGN ��- Is the facility loaned on NKti�m+RaSenalloll er <br /> FACILITY TYPE yy`1.MOTOR V£H1C.l�FL'£LING ❑ Trast q�g? []Yes �No <br /> f 11.FARM ❑ 6.PROCESSOR D 6.OTHER <br /> IL PROPERTY OWNER.INFORMATION <br /> .os. <br /> ao'I. PHONE <br /> pROPEIIY OWNER NAME <br /> ' y,ja — iQ I <br /> �f6-LTE r <br /> MAILING ADDRESS <br /> ufl]. <br /> I& ODE <br /> I2O5 T="� aro. STATE "f ZIP C <br /> CITY R5 i <br /> K S� <br /> M. TANK OPERATOR INFORMATION <br /> ^isi. PHONE <br /> TANK OPERATOR^NAM.E <br /> MwfUNO ADDRESS <br /> aa4 <br /> a±6a STATE < -s ZIP CODE <br /> CRY <br /> i <br /> IV. TANK OWNER INFORMATION als. <br /> ain. i PFK/NE <br /> TANKOWNB7t NAME � � � ) <br /> aK. <br /> MA1LBKi ADDRESS l». <br /> air. : STATE aii. DP CODE <br /> CITY <br /> am <br /> OWWM TYPE: ❑ 4.LOCAL AGENCYTOLSTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY <br /> ❑ I.FEDERAL AGENCY [] S.NONlAVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER ,zf. <br /> Catl 6+e Stalc Bmrd oT Equalt]atien,FuG Tax Divi3l a,ifdh aegnMfeas. <br /> TY(TK)HQ 44- i <br /> VI.PLRMCf HOLDER INFORMATION <br /> I.FACILITY OWNER Q 4.TANK OPERATOR <br /> Lie per>mt aed Smd kpAl»otificatialls md maitwgs lo: 5.FACILITY OPERATOR <br /> p 3.TANK OWNER ❑ <br /> SUpERVl9OR OF DIVISION,SECTION,OR OFFICE(Required For WMic Agent <br /> ks Only) <br /> VII-APPLICANT SIGNATURE ry <br /> soca and ie fa 43. <br /> CE f¢iCAMN: L tIM1 Me Lef0ra]aLlee evfdr4l berEl®� DATE 1 PF{ONE ,L I—. <br /> APPLICANTS TURF <br /> a16. APPL.ICANTTTLE -I <br /> APPLICANT NAME( eOt )E <br /> fz <br /> completed <br /> IJPCF I16'[-A Sev.(f2fAO1) <br /> Cl0/600 'd 46ZO# aoeid;a�aeW Aijunoo 9ZZZL1+660ZL LZ: 6L OLOZ/40/b0 <br />