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$-12-1999 9.52AM FROM P. 2 <br /> UNIFIED PROGRAM CON$01-IDATEO FORM 2NK <br /> UNDERGROUND STORAGE TANKS — FACILITY <br /> '�(L <br /> TYPE OF ACTION P.9a _ 4 <br /> (TYPE OF CTI r 1.NEW SITE PERMIT r 3.RENEWAL PERw r S CHANGE OF MFORMATION(Spx.Ny&-wII. r 7 PERMANENTLY CLOSED SITE <br /> r 4.AMENDED PERMIT r 8.TANK REAMED 400 <br /> r 5.TyAPORARY SITE CLOSURE <br /> Lti yl S I.FACILITY I SITE INFORMATION <br /> BUSINESS NANE(SaWn FACILITY NAME o OBA-Ow,Busm�ss`.Ajs) ]c FACMY IDs <br /> NEAREST CR EET /��p1 <br /> FACILITY OWNER TYPE r 4. LOCALAGENCYJCMTRIOT <br /> V r ,. cORPORAnow r a COUNIYAGENCY- <br /> SUSINESS TYPE r 1,GAS STATION 7.FARM r S.COMMERCIAL . INOMOUAL <br /> r 2.OISTRIBUTOR r 4.PROCESSOR Y8.OTHER r 3, PARTNERSFOP 7.r` FE�AGENCY AM <br /> 407 <br /> TOTAL NUMBER OF TANKS Is fuAiy an Inman Rasmv n •K�d UST 4.pdAK a9 .named P I,iaf IX <br /> REMAINING AT SITE A'a-IIIII"Ib9 dw.,gnian ar olf �t Aw a UST, <br /> / ITtlis.:..1s oat'.ra:pe(Sa>w Rr+aefk�wGeh.) <br /> 40a r YAs Na d65 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 NE 40B <br /> m! . kl� a CN�Nvt �2 zo-i ¢- <br /> NWRING STREETApDRESS <br /> 3! Q 409 vpi <br /> 1 at A 411 P C DE 412 <br /> sToc cA , tisz05 <br /> PROPERTY ONMER TYPE INDIVIDUAL r 4. LIXll AGENCY!DISTRICT r B. STATEAGENCYet3 � <br /> r f CORPOPATIO14 r 3, PARTNERSHIP r S. CoUNTYAGENCY r T FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> YIWK ONMER NAME a+a E a+s <br /> M ti/i e 209 ¢- 73 74— <br /> "LING Oft STRPETADDRESS els <br /> !ST <br /> CIIT .11 418 ZIP CODE 419 <br /> 57nc-KI olJ �-A. 9S205 <br /> TANK DOURER TVP �INDNIDUAL r A. LOCAL AGENCY I CISTRICT r G STATE AGENCY 4Z0 <br /> r +. CoFPOR,-ON r 3. PARTNERSHIP r 5. COUNTY AGENCY r T. FEDERALAGIINCY <br /> pi 8JAID 13E EQUAl 170110m(IST STORAGE FEE <br /> TY(TK)HQ a a 1 - I I 11 69 if gtae bti afire w <br /> INDICATE METNOD(S) r 1. SELF-INSURED r e. SURETY Son 7. STATE FUND r 1p. Lo0ALOovomECWINISm <br /> r 2 GUARANTEE r B LETTER OF CREDIT T R STATE FUND 6 CFO LETTER r W. oTHm <br /> r 3 INSURANCE r S. ExafmoN r S. STATE FUND&CO 422 <br /> coca!ataEastonaeMswhiRYaaaffMsrwNMIN, ImMOM rdw4fi80ASMfdmelrg r 1. FACEITY . PROPERTY OWNER r 3. TANK OWNER 4Z7 <br /> Leah ngNofms arra matiras x+u m zad ro tia tank aAnw unWcs aAs 1 pr Z li pagpp <br /> VU APRLjCAhCC-SM&7lIRr- <br /> CertiTKaflell: I a4IIdY Mat Ifla atpmggn P1aYbW INI441 H IfIN aA9 aOTI1MB a aro lMN d a+y Mleabaga. <br /> SIGNATURE OF APPLICANT: //�^ GATE 7 q aZa P O —7 Ll 4 4" <br /> � <br /> NAME CF APPLICANT(pn �7 D � 428 TIIt,E OF T ' w� <br /> STATE UST FACILITY NUMBER(Fm b .A td W 428 '998 UPGRADE CERTIFICATE NUMBER(PoT A)Oal USB ONY) 429 <br /> I <br />