Laserfiche WebLink
lwdnED PROGRAM CONSOLIDATED FOa <br /> TAI`iKS <br /> UNDERGROUND STORAGE TANKS -FACILITY !� <br /> ,_,/ (One page per site) Page_of <br /> TYPE OF ACTION ,t?+•NEW PERMIT [3 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> Y ❑4.AMENDED PERMIT (Spmify change) [3e.TANK REMOVED <br /> (Check one item only) SITE CLOSURE <br /> I. FACILTTY/SITE INFORMATION <br /> 4K B1i5LNESS NAME(snnea FAC7LITYNAMEE DBA-Doingaurinnr As) s. FACISI t <br /> l� .J 11LG <br /> N ARESTCROSS TRE T <br /> � ant. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT' 4oz <br /> S � -T / S� ❑1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS I.GAS STATION N FARM S.COMMERCIP.L ws. ❑2.WD[VtDUAI- ❑6.STATE AGENCY' <br /> q. [16.OTHER .PARTNERSHIP ❑7.FEDERAL AGENCY- <br /> TYPE ❑2.DISTRIBUTOR ❑ PROCESSOR ❑ <br /> TOTAL NUMBER OF TANKS 404 Is facility on Indian Reservation 405. •If oumer of UST is a puhlic q=y: mrru of supervisor of division.section or 404 <br /> REMAINING AT SITE or trust office which op==the USI. (This is the contact person for the tank records.) <br /> lands. <br /> ❑Yes jZ4.10 J Eri�Z�t iz 1 <br /> H. PROPERTY OWNER INFORMATION <br /> 47. PHONE a0t <br /> PROPERTY OWNERc -3-3 C� <br /> MAILING OR STREET ADD SS <br /> /0� S Oto. STATE All.. ZIP CODE az <br /> CITY , C7 <br /> "/ 4.LOCAL AGENCY I DISTRICT 6.STATE AGENCY 11J <br /> PROPERTY OWNER TYPE LCORPO RATION 2.INDNIDUAL <br /> O.PARTNERSHIP ❑i.000NTY AGENCY C17.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> J 414. PHONE 6 �+ 411 <br /> TANK OWNERN T / <br /> J aa. <br /> MAIL ORS ET ADDRESS <br /> CITY <br /> ,/ �7 �+ 417 STATE 4u ZIP CODE 419. <br /> f 3l// to L_ G ' ��ZS� <br /> 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 4m, <br /> T.ANKOWNEK TYPE 1.CORPORATION 2.INDIVIDUAL 7-FEDERAL AGENCY <br /> .�3:`PARTNERSHIP ❑5.COUNTY AGENCY ❑ <br /> W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Call 91 322-9669 if uestiolls arise i21 <br /> TY TK)H 44- <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> NDICATE METHOO(s) ❑ 1.SELF-INSLRED ❑4.SURETY BOND ❑7.STATE FUND - ❑ lo.LOCAL GOV'r MECHANISM 422. <br /> INSURANCE ❑6.EXEMPTION REDIT [3 9.STATE FU`D&CD LETTER 99.OTHER_- <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cbeck one box w indicate which address should be used for Iega1 aoti0catioru and mailin& J P-GPERTY OWNER [3 3.TANK OWNER 425. <br /> Lcgal muff atioos and treilings wi11 be sent w the tank owns unlet box 1 or 2 is checked. ❑ 1.FACILITY/ 7.-PR <br /> VII.APPLICANT SIGNATURE <br /> Cemlicadow I certify that the information provid herein is etre and acemare w the best of my knowledge. 25. <br /> DATE 424PHONE n1V <br /> SIG RE PLIC T } 3 3 7ear <br /> 427. <br /> 426. TITLED PLICA <br /> N F APP T riot) /V <br /> z iZf C/ Z / .z9 <br /> 425. 11998 UPGRADE CERTffICATE NUMBER(Asew.y use wh) <br /> FTEUSTFACILrTYNUMB R(Agmryuraaaly) <br /> Data Element 1,above. <br /> Rev.021100 <br /> UPCF Hwfwrc-a(1/99)-1/2 httpd/www.unidoc&org <br />