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UNIFIED PROGRAM CONSOLIDATED RM TANKSUNDERGROUND STORAGE TANKS -FACI L�TY�per aim)Aoo <br /> Pip-of- <br /> C3 <br /> G7+.NEw PERtiTi ❑7.RENEWAL PERMIT' ❑S.CHANGE OF LNFORMATION [37.PERMANENTLY CLOSED SITE 100, <br /> TYPE OF ACTION �j p S.TANK REMOVED <br /> 4.AMENDED PERMIT (SPccih change) <br /> (Check ane item odv) ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(S „FACI71TrNAMEEq.DaA�Oo�iei a"r'"pe Ast s" IDBI <br /> LITY <br /> ate `5 <br /> 7s�1 L AVVL� not. FACILRYOjER TYPE U 4.IACALAGENCYIDISTKIUI 107- <br /> h AREST R/Oop TRE ❑1.CORPORATION ❑5.COUNTY AGENCY' <br /> ' - �� S/5.COMMERCIAL 1Oa' [12.�IVmU`L ❑6.STATE AGENCY• <br /> BISINESS 1.GAS STATION FARM 6.OTHER .PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ name of supervisor of division.section or nei <br /> no+. (s facility on Indian Reservation us. •if owtter of u5T is a public a¢ocy: <br /> TOTAL NUMBER OF TANKS office which opmous the UST. (This is she contact person far the resit tewtds) <br /> REMAINING AT SITE or mssc lands? <br /> ._ . /z J^ <br /> ❑Yes Jz'xo <br /> II. PROPERTY OWNERINFO11MXTION me <br /> ao7. PHONE p <br /> PROPERTY OWNER NAME 33 / <br /> � es .�. <br /> MLAIL ORS ET ADD S <br /> tit. ZIP CODE_ (y alz <br /> oto. STATE `/1 3 <br /> clrY L 4/ � �. <br /> ores. <br /> d.LOCAL AGENCY I DISTRICT 6.STATE AGENCY <br /> OW <br /> PROPERTY NER TYPE i.CORPORATION ?:INDIVIDUAL IP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> $.TANK OWNER INFORMATION nts. <br /> Alk PHONE s©� 7 ' <br /> TANKOWNER NAME � J/ �S' (� J <br /> oti/J - <br /> MAIL ORS ET ADDRESS <br /> Sn(a ZIP CODE ,�+- n19 <br /> nn. STATE� �S"ZSp <br /> CITY <br /> 14' 4.IAC.AL AGITICY/D4STRICT fi.STATE AGENCY +20. <br /> LCORPORATfON 2.INDIVIDUAL 7.FEDERAL AGENCY <br /> TANKOWNER TYPE <br /> i.PARTNERSHIP ❑5.COLN AGENCY ❑ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER at. <br /> TY H 44- <br /> Call 91 322-9669 if uestions arise <br /> ) <br /> V.PETROLEUM UST b ANC'AL RESPONSIBILITY <br /> SURETY10.LOCAL GOVT MECHANISM ser <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED [3 4.5.LE.I.I.ER OPND [3 7.STATE FUND <br /> CREDIT ❑S.STATE FUND&CFO LETTER ❑99.OTHER <br /> IINUSURANCE ARANTEC3 6.EXEMPTION [3 9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check ono box to indicate which,date,,should be used for legal notification and mailing. 1.FACILITY/ ROPERTY OWNER ❑3.TANK O WNER <D' <br /> Legal notifications and trailings will be sent m the tank owner unless box 1 err 2 is checked. ❑ <br /> VII.APPLICANT SIGNATURE <br /> 2. <br /> Certification: I certify that the infortmtion pmvi herein u Rue and occtn-ate to ate best of my Dw�gn• nu. PHONE <br /> A �X:57 " <br /> SIG RE PLIC T O- 7 3 3 +n_ <br /> +�. TITLE 0 PLICA <br /> N F APP T rint) - <br /> iZf C/ Z <br /> +erg 1199E UPGRADE CERTIFICATE NUMBER(Agenry care nob) <br /> STATE UST FACILTLY NUMB R(Agme7 we onryl <br /> lSee Data Element t.above. <br /> Rev.07JI6l00 <br /> http:ywww.unidocs.org <br /> UPCF HwMrcn(1/99)-1/2 <br />