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NOV-20-2003 14:10 FROM:CDS PURC'' SING DEPT 209 9378855 TD:4640138 �L\Ll.��9,004 <br /> y <br /> 11/20/2003 09:04 2094633 FIFTH FLOOR 'S PGE 02 <br /> LFNIFIELF PROGRAM coxS[R$AATTD 80RM S , PACM <br /> UNDERGROUND STORAGE TANKS -FACS JT'Y 1�z� �03 <br /> m.rawmae* _./ihs r <br /> TYmwAcTx3H ❑ I.Nnw arm pu- T ❑A.KC BWAL PPR A.CW=0FINMRMMATpl1 <br /> (Ope�,❑�1{.}®IAAN6N'I1XflA9RP <br /> iM eeoe mm}] ❑,.AMRIfDRD PF]!MI'f TANK REMOVFD <br /> Q e,TDMFCRAAT 8IT C106(RU'- ieo <br /> L IFACUM I SITE INFORMATION w <br /> 8U (6EL,mneT _ CIM <br /> WMld1AM- S f F 1 <br /> STCRA55 NI F�A.( LITY �e,L1+1`...A9RMCYry16TRiCl` <br /> iQ I.MRIAMATICN ❑S.CvurcfX AORdCV' <br /> 1,6ASSTAnW ❑LFARM 0 A.CCRnw"R ❑s MO1VmUA[ p R6TwTEA06NCY � <br /> FYPE ❑2.mn7BuTYN1 ❑41mo 666OR Cama 11mt ,m ❑LPARTNRM1TI6B ❑f,FIDRRALAO�1CYt <br /> ALNUZvMlL In ownlym Q. or •tfewv.-wino noboArmor. eesmFem-ova"'Im mom e6ltnaFkR t6TTam <br /> ROdABV66G ATSFYE mudmw 6rc U6T(5fie is+lemaRRpelrn mmm�l TeeeleN <br /> Am []Yn [ANO na <br /> u.PRoPERTV OWNER reoRMATION <br /> MOPSMOWKERNAM +a <br /> oa a <br /> C-L arada <br /> CITY 41n 7A'YE eu <br /> 9szo Z --/?f 7 <br /> VROPWY OWQER TYM pl,copFORATm o 7.DQnVMUAL M A.LOCALAGENCYto)STAIM CI 6.STATE;AGH4CY <br /> ❑1.PA1tTN ❑s.COUNTY ACiMCY ❑7.PEOERA.LACEWY e1 <br /> III.TANK OWNER INFORMATION <br /> LOXOW�MRNAME ,N 1V <br /> 630 KESS 41e <br /> ON <br /> A ,le e19 <br /> IIT <br /> TANKOWMTYPE ❑I.CORPORATION ❑2.1 MVMUAL M A.LOCALA0377CY/DI6Y'R= ❑6.STATE(AGENCY em1 <br /> CI IFARTN6D86(9 ❑$.COUNTY A(GEMCY ❑7.PELISRAL AGH4CY <br /> IV.BOARD OF EQUALIZATION UST STORAGE PEE ACCOUNT NUMBER <br /> TY " calf 916 333-9669 if uelnlaBR nsix e1 <br /> V.PETROLEUM LIST FINAWAL RE9PONS0HXrY <br /> INAICA.TSMETHOD(s) p 1,SRP,A/RUREID ❑A.SURETY 3= ❑ 7.STATE RINP ❑ 10.LOCAL30VTNMCHANISM <br /> 02.GUARANT32 05,iXn76R9FCU= ❑ l,SLAMFUNDRCFUJBTTER 1;kmoP,1�,�8,, <br /> 03.MS(1RAN(1: 06.E7@rTIDN ❑ 9.0TATRF=,A.CO <br /> VL LEGAL NOTIPRCAMON AND MATLINO ADDY= FSF�4e <br /> Cbna oee boem kl&n Whild DNmm a W beowl6nrTAai11nn6eetiatsnM elemnR. 1mv I.PACWTV ❑2.PROPBRT)'0WNER M&TAMOVlNFR Q1 <br /> 1.tAA nal6rnbro eeewamR,inYa eaN M1�t 4NLmrvcabebeR t a�G 011te1M <br /> APPLICANTSIGNATUXX <br /> CnA6oelmn•e m%Nt IooaleopnTdeee b-b le Ret mA emlmam e.r.rzeSlro'1mNn64+ <br /> GNA °A <br /> AME nnn <br /> $IATA UBTPACB.fl'!fNUNIDBEtOertedmaM (998 UPGRAAB CSR liUlNBBR �vew,M ,a <br /> le 1990 CaogM+ <br /> uPCP(1199mised) <br />