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UVIED PROGRAM CONSOLIDATEDRM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> I <br /> (one page per site) <br /> Page , 3f _ <br /> YYPE OF ACTION 1.4EW SITE PERMrr F 3,RENEWAL PERMIT C- 5.CHANGE OF INFORMA�CN 1Syeary rnI- r 7.PERMANENTLY CLOSED SITE <br /> IChecx one dem onfyl ]- 4.AMENDED PERMIT ;oval use only! r 3.TANK REMOVED AM <br /> 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY 1 SITE INFORMATION <br /> 3USiNESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY'0 i I I <br /> rp-III i <br /> �ptt,l�►L �7G LL, <br /> NEAREST CROSS STREET 101 AGILITY OWNER TYPE I a. LOCAL AGENCYlOISTRICT' <br /> 1. CuRPORATION <br /> _ T- 5. COUNIY AGENCY' j <br /> BUSINESS TYPE r I GAS STATION r 3.FARM \� 5.COMMERCIAL_ r 2 ;NDMOUAL [-5. STATE.AGENCY- <br /> 2.DISTRIBUTOR C 4 PROCESSOR ZI 6.OTHER r 3• PARTNERSHIP [- T. FECERALAG+ENCY- 402 <br /> 403 <br /> TOTAL 4UMBER OF TANKS 's scaly an Imran Reservation or .If owner of USS s a ouDec agency:name cr swervlsdr at ` <br /> REMAINING AT SITE trusdanrls? jivlswn,se=n or atiice wmcn operates the UST. i <br /> t'- (This is me dpntac Deman for the tank n�arOL 1 <br /> 404 L Yes No 405 406 <br /> ll, PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 I <br /> -PAtc114:71, C_ 36-LL.._. - 3 (09 2 <br /> :MAILING OR STREET ADDRESS 409 I <br /> ENV[9,0MR1,x L.-- 'Nl+°�*t�t-�� 1` '5!2Q <br /> CITY 410 STATE 111 ZIP LODE 412 <br /> Rr'�vw ? 9 45S -09 9 5- <br /> PROPERTY OWNER TYPE I- 2. 'INDIVIDUAL I- 4. LOCAL AGEDICY 1 DISTRICT 3. STATE AGENCY 413 E <br /> I,. CORPORATION [-' 3. PARTNERSHIP r S. COUNTY AGENCY r 7 FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 115 <br /> MAIL,NG OR STREET ADDRESS 316 - <br /> "LL�'1 r'T S 1�© SCS a <br /> 417 STATE 31B 2]P CODE 415 <br /> WANK 'JWNER TYPE [� 2. INDIVIDUAL r 4. LOCAL AGE31CYi DISTRICT L 6. STATE AGENCY 120 <br /> I. CORPORATION <br /> )� 3. PARTNERSHIP C� i COUNTY AGENCY 7. FEDERAL AGENCY <br /> TY cTK) HQ 4 4 � 1 �1 � Call(916)322-9669 if questions arise 421 <br /> El <br /> INDICATE METHOD(S) I SELF-INSURED r 4. SURETY BOND F 7. STATE FUND T� 10. LOCAL GOVT MECHANISM <br /> r 2. GUARANTEE I� 5. LETTER OF CREDIT r 9. STATE FUND 8 CFO LETTER C 99. OTHER: I <br /> 3. INSURANCE 5. EXEMPTION r 9. STATE FUND 3 CD 422 <br /> Cnedt one Dox to Intllcata wrvc11 address snouts be used for Iegai notlficauors and mating. r 1. FACILITY r 2. PROPERTY OWNER r J. TANK OWNER 323 I <br /> I eaar natifRcanans Ona matlinds will 6e sent to the tank owner ctrlless btSx 1 or 2 is c necked N/11 A221 ICANT!c;fG?JATI IRE <br /> Cantfication: I Certify that the Informattan arovided herein is vue and accurate to the Celt at my knowie0ge. <br /> SIGNATURE OF APPLICANT DATE - 424 PHONE 425 <br /> NAME OF APPLICANT ipnntl 426 71TLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Far focal use only) 428 '958 UPGRADE CERl'FICATE NUMSFR(For rocas use only] 429 <br />