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Ja9, 17. 2007 3 04P T 'D Facilities 0839 P. 2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM FR& 3A) <br /> ( � ^ FAC 4• <br /> UNDERGROUND STORAGE TANKS -FACILITY 0' <br /> (oneP� Wk) <br /> TYPOOPACTION ❑ I.NEwRITB rmwir ❑3.R1411WAL POLMIT ❑ 3.CHANCE Or WORMA-MON ❑7,PEWANMY Cl Dare <br /> ICLaF one loe onNl pd;1 r� rirl A TANK lLNOYPM <br /> ❑4.ApikTNpaD rERMIT �6&S'd`( CL(WI, 4„�. �j^�.,'`^1�P0. <br /> �•: <br /> ❑l,TEMPORARY I'fSCL09lIR6 uq <br /> 1.FACILITY I SITE INFORMATION I <br /> ISUSI J � r .cai [ILlW MAV.;G Lr <br /> PR IDN' <br /> 1y ✓ I <br /> NP.ARL7ST CR08 AL. R401 rYpE Ell,Ell,LOCAL AGENCYt=AICTe <br /> ❑ I.Cotpouncri C) S.COUNTY AORWY• <br /> BUSINESS ❑ 1,OAS STATION ❑3.FARM ❑ 7.COMWERCM El 2.INPIYIOVAL -254JITATEACfaNCY- <br /> TYPE ❑2.IIISTRIBUTOR ❑4.PROCMOR ;540TIM ell ❑3.FAMWORSMr ❑ fG01a <br /> 7. 6RALAGRNCY• <br /> TAI,NUMBER,UF'TANKS ! ryDh nom arnmll9em -IH¢vaer Q(LW Iea rM4lk RIM:MinaefmrNbld <br /> . ®retaon.mum.ldr=.106 <br /> REMAINING AT SITE dmde7 Ns USr(TM}e B9nwntaolP+lml rarlh¢�nk reeew4. ,} <br /> t,l N X- ❑ Ya Nn D<btisN�. WeL •{9t� ai <br /> H,FRO PERTY.OWN <br /> `E1RINFORMATION <br /> ER3'Y OWt•ISR NAMt '""l'n . lI-7E� S�Oi ILLS I�C.I � M' C,Q -p 3� - ��7 <br /> 'Wml <br /> U M MEI MMRMS 1KLt 4405(N L o <br /> wW <br /> CITY 419 � a �j-13 7 Ilt <br /> PRMXTY OWNER ❑ I,CORPORATION ❑ 2TKDIVTDUAL 04,LOCAL AGENCY/DISTRICT �lk STATE AGENCY <br /> 03.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.rEDER.ALAGENCY 115 <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWV MAMET <br /> 2a Sad.-�vl ors ` L• &-3caY9 <br /> MAILIKU 410 <br /> CITY 117 STATE /•I 4111 ZIP <br /> 537 -19 <br /> C.-flr <br /> TANK ER I yft Cl I.CORPORATION Cl 3.INDIVIDUAL ❑4,LOCAL AGENCY/DISTRICT "K 6.STATRAOENCY 41 <br /> ❑3.PARTNERSHIP ❑ S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> TV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 4d- <br /> Call 916 322.9669 if question!arise 1t' <br /> V.PETROLEUM UST FMANCIAL RESPONSIBILM <br /> MOICATIME71 MI) C3 I.SMp.INSURE) ❑4,SURETY BOND ❑ 7,STATE FUND ❑ 10.LOCAL GOVT MECHANOM <br /> 112.GUARANTEE ❑S,LETTER OF CREDIT Cl R,STATE FUND&CFO LETTER PL99.OTHB/jµt `` 4.,� <br /> ❑F.INSURANCB ❑h EXEMr1'ION 13 9.STATE FUND&CD s(.{-[O D 1 fl- 5!1 1 <br /> V3.LEGA.L NOTIFICATION AND MAILING A <br /> D <br /> (DRESS <br /> t <br /> Clek ena laA lAlndtene wAW kdnN+houldkBPed 1prlgel refiflemlmnv emmli.q [] 1,PAcrLrrY X12.PROPERTY OWNER 03.TANK OWNER 4v <br /> LqN eellA,xUm7 Md meH'vg will Fs eme to the bnS w7ler.mLe4 eat 1vEtlahmk�d. <br /> APPLICANT SIGNATURE <br /> lmdpeplm.Iaei1yIm,the jnfmmcim mvida 7omin iv noe■w�w w%ht 00¢rm7 krnA¢dye <br /> TUREOFAPPLI�NT� OATS q4 PHUN n.7 <br /> I Ua' 1 1 0 o� 3a -3 WO K i <br /> 'r(prim) 43A T APf7JCAN'I' 47 <br /> t�r-redmr � •u3 ' <br /> STATE UST FACILITY NUMBERCTr Iml.c^•u 4th 199P UFORADE CERTTRICATENUMBER(wrlp+vaaMJ 427 <br /> IL 1998 CompllulQ <br /> UPCF 0/99 revised) <br />