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FIED PROGRAM CONSOLIDATED I M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> GIN owe Dor say <br /> Papa L d M / <br /> (C^�h.OF AMm�M) ❑ 1 NEW 511E PERMIT J.RENEWAL PERMIT [3n Mrp- <br /> S.CHANGE OF INFORIMTION(Spa - 1 PERMANENTLY CLOSED SITE <br /> ..AMENDED PERMITanb/ bcN uaa ❑ 8 TANK REMOVED .00 <br /> I.FACS.ITY I SITE INFORMATION <br /> BUSINESS NAME BS M FACILT'NAME a ORA-D mg I mu M Aa) 3 RACILTTY 10 Y 1 <br /> I, <br /> NEAREST CROSS STREET 401 is 1. <br /> OWNER TYPE ❑ l LOCAL AGENCYIOISfRICf` <br /> N, YY�ACA RT}�l1 CZ 1 (� yi. CORPORATION D 5 COUNTY AGENCY• <br /> BUSINESS D 2. INDIVIDUAL D 8 STATE AGENCY* <br /> TYPE D 1.GAS STATION D 7,FARM D S.COMMERCIAL D 7. PARTNERSHIP <br /> D 2.DISTRIBUTOR �..PRCCESSOR D 8.OTHER 407 [3 ]. FEDERAL AGENCY• .02 <br /> TOTAL NUMBER OF TANKS b fs11ly W Wien Ranrvatlm a 'll PMMI d UST•p8W qp n MIW d.p d <br /> REMAINING AT SITE I1sWnWT Eiviaian,nCIa1 a alf w M1kCN opataba BN UST. <br /> O .W (TNa s tl,a anOu1 paxam M 81a ttnR tacoNs.) .08 <br /> Dy. oNo .NJ <br /> R.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME G2ovC' PH <br /> .D] �a5- 866 - 807o <br /> MA0.Pq OR STREET ADDRESS <br /> 3( t4z\w <br /> CT SRN 2[Y Y(Y10 410 1 STA% n, ZIP COOEq <br /> II L�j0 412 <br /> PROPERTY OWNER TYPE El 2. INDIVIDUAL D DW <br /> RCT LOCAL AGENCY/ D e. STATE AGENCY 413 <br /> OR 1. CORPORATION ❑ 3. PARTNERSHIP D 5. COt1NrYAGENCY D ]. FEDERALAGENC/ <br /> IB.TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> t CCLa,tsGRou <br /> 6CLoo�c � • • qa <br /> 415 <br /> T}# <br /> MAILING OR STREET ADDRESS 418 <br /> 31 �o cQow Cf�Yo.a ��0 5v 1T� as v <br /> CITY .l] 1 STATE .18 21PCODE .19 <br /> 4 58 3 <br /> TANK OWNER TYPE �y ❑ 2. INDIVIDUAL D .. LOCAL AGENCY/DISTRICT ❑ 8. STATE AGENCY 420 <br /> Su 1 CORPORATION D 3. PARTNERSHIP D 5. COUNTY AGENCY ❑ T FEDERALAGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO 4 4 - Call(916)322-96M if quoshm wise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(S) D 1. SELF-INSURED D .. SURETY BONO D ]. STATE FUND D 10 LOCAL GOYT MECHANISM <br /> D 2. GUARANTEE D 5. LETTER OF CREDIT D a. STATE FUND 8 CFO LETTER ❑ W. OTHER: 422 <br /> 7. INSURANCE ❑ 8. EXEMPTION D 9. STATEFUN08CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chmk oro t m mJwM+ ick aoM1Ma 1APu1I W uaa8 M Nyl mNicaeona ami"1109. ❑ 1. FACILITY 2. PROPERTYOWNER D 3. TANK OWNER 423 <br /> Leal ndR�O a W..dm,v W MM W 81a bnk p vMl union Mu 1 a 2 n ck.Ckad. <br /> VII.APPLICANT SIGNATURE <br /> C.mlkaWn I comfy mK"IMama m p,pW W MIM,r PIM a,k accuM m"ka.t d my knOMM9a <br /> SIGNATURE APPLIC .2. PHONE .25 <br /> '^' 3 14 -ao�� ao°� -5a�(-9bs3 <br /> NAME OF APPLICANT(pnn0 .28TITLE DF APPLICANT 427 <br /> Acer <br /> E _ 1 /�h St�1'30'VV <br /> UPCF( Fommly SWRCB Form A(1140) � � C / 1 y a <br />