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UN ' ED PROGRAM CONSOLIDATED r RM <br /> .s TANKS i <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) I <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Speafy Waage- *k7 PER TLY CLOS <br /> (Cnecs ons item only) r 4.AMENDED PERMIT %oral use only) ra.T <br /> r 6.TEMPORARY SITE CLOSURE <br /> JT I.FACILITY I SITE INFORMATION r <br /> BUSINESS NAME(Same as FACILITY NAME or 05A-Ommg Business As) 3 FACILITY 10 s <br /> Fowt .6W5 a0D SEtbP '11x. <br /> NEAREST CROSS STREET40t yFFeAeCILITY OWNER TYPE r 4. LOCAL AGENCYIDISTRICT' <br /> aLV. CORPORATION r 5. COUNTYAGENCY' <br /> BUSINESS TYPE r 1 GAS STATION r 3.FARM S.COMMERCIAL r 2. INOMDUAL r S. STATEAGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 7. FEDERALAGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is faalily on Inoue Re at.or -s owner of UST.a a Public agent:name ct supavoa of <br /> REMAINING AT SITE buaWtla? arvuion,seaban or office whiff%aparales Me UST. <br /> (Thu is me mntaa person for the tats records.) <br /> /���[-yens�" �N406o 405 <br /> To"rl'1C 6 e$( F ��%R IJ Cr- 1.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 p�� �O <br /> Qo oW /` <br /> MAILING OR STREE1rJAODR S 409 <br /> A 0 <br /> CI 410 STATE Ott 21P CODE 412 <br /> OC.{LTa GA <br /> PROPERTY OWNER TYPE 7c., INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 5. STATEAGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7 FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 015 <br /> Slpr � N'S <br /> MALNG OR STREET ADDRESS 416 <br /> CIT" 417 STATE 418 LIP CODE 419 <br /> TANK OWNER TYPE r 2. INohnouAL r 4. LOCAL AGENCY I DISTRICT r 6. STATEAGENCY 420 <br /> r 1 CORPORATION r 3. PARTNERSHIP r S. COUNTYAGENCY r 7 FEDERALAGENCY <br /> TY(TK)HO 4 4 Call(916)322-9669 if questions arise I 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND 7. STATE FUND r 10. LOCAL GOVT MECHANISM <br /> r 2. GUARANTEE r S. LETTER OF CREDIT r B. STATE FUND a CFO LETTER r 99. OTHER <br /> r 3. INSURANCE r S. EXEMPTION r 9. STATE FUND&CD a22 <br /> Chsck We bos to hd.te whirl)asaess shouts W uses for wad mlifimtiona ant mail"u1g. r 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Localacoheatiore an. r -n ba n h kunless oox 1 of 2IIs heck <br /> Ceh4wm n inform n Pht-es herein a we sad acovats to the best of my knowledge. <br /> SIGNAT E O , - _ ��J �a ___ d24 MON O 425 <br /> NAM OF CAN (pmt) 428 TITLE OF APPLICANT \ //Qs� 427 <br /> p L-412-- <br /> M <br /> 4�- <br /> STATE UST FACILITY NUMBER(For rota)use aHyl 428 1958 UPGRADED UMBER(F4vbcauseanly) 429 <br />