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UNDERUROUND STORAGE TANKJ -FACILITY TANKS <br /> t (one page per site) <br /> Page _ of _ <br /> TYPE OFACTIONitem o )'7.PERMANENTLY CLOSED SITE <br /> (Check one My) I'7.NEW SITE PERMIT r 3.RENEWAL PERMIT CHANGE OF INFORMATION(Spetity charge- <br /> ]-4.AMENDED PERMrr local use onN) F B.TANK REMOVED 400 <br /> I'S.TEMPORARY SITE CLOSURE <br /> SU(\$ISH\�JESS NA,Mr\�E`('S]a^me`/as FACILRY NAME o(rO�BAr-�D,nar\g Business As) 3 # # 1 <br /> NEARESTCROSS STREET 401 F CILITY OWNER TYPE ]'4. LOCAL AGENCY/DISTRICT' <br /> Y,a(/"R n 1. CORPOPATION r S COUNTYAGENCY• <br /> B INESSTYPEa r 2. INOIVIOUAL r 6. STATE AGENCY' <br /> �4.GAS STATION I.3.FARM I'S.COMMERCIAL ]"'3. PARTNERSHIP <br /> I.2.DISTRIBUTOR r 4.PROCESSOR I.6.OTHER I.7. FEDERALAGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS b fadllly on N�dan Raservalun ar •M owner of UST is a public a FoW..name of suRmisof of <br /> REMAININGAT <br /> SITE <br /> /J(/' Wstlands7 dfvbion,setion or office which operates the UST. <br /> (This is the contact person for the lank records.( <br /> 404 ]'Yes No 405 406 <br /> 'LgLw�.i •'• �}" '7.Is h.'--`7 'l '.'.= 4 MkE.�x,.�s iu- .t[ani <br /> PROP OWNER NAME 401 PHONE 406 <br /> MAILING 4Z!Z ¢ !�ADDRE 409 <br /> CRY D\\ \� STAT 477 ZIP MZq_ <br /> PROPERTY 07ANER TYPE ]•z INDIVIDUAL I. L LOCALAGENCY/DISTRICT IF G. STATEAGENCY 413 <br /> I. CORPORATION ]-'3. PARTNERSHIP - 1-5. COUNIYAGENCY I'7. FEDERAL AGENCY <br /> »,+TANKOWI4ER INFORMATION <br /> . -. <br /> TANK OHNE E 414 <br /> MAILING E AOORESS 416 <br /> CRY - - ST 41B ZIP CO ` <br /> TANK OWNER TYPE r z INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r S. STATEAGENCY 420 <br /> J71. CORPORATION r 3. PARTNERSHIP I'5. COUNWAGENCY r 7. FEDERALAGENCY <br /> �11ll� 'ACy;.p1JMT_ .s <br /> s ..t ka:^� <br /> TY CfK)HQ 4 4 - Call(916)322-9669 if questions arise 4zt <br /> LF-U <br /> N' y SELF-iNSUREO 1'4. SURET(a NU ')' 7�STAiEFUNO P`7o LOCAL.,O'J MECHANISM ' <br /> F 2. GUARANTEE I'S. LETTER OF CREDIT I'e. STATE FUNDS CFO LETTER ]'99. OTHER: <br /> I.3. INSURANCE FS. EXEMPTION I 9. STATE FUNDS CO 422 <br /> Lethal notifications and mailings wM be sent to the lank owner unless box l or 2 is checked 1. ICI k"op MMER F 3. TANK OWNER 423 <br /> Na <br /> ,.- 449VLNXI.. <br /> Certification: 1 cer0y that the Mann tbn etl heren is We and accurate to the best army knowledge. <br /> 1IGNAMP#WV DATE A' '- 'E <br /> s �6 zv �l6 (a, W. 1125 <br /> NVRE7QF APPLICAD - 426 <br /> 10azos Com. <br /> STATE USTFACILRY NUMBER(F.11,111 use ally) 428 1996 UPGRADE CERTIFICATE NUMBER(Forlocal useonly) 429 <br /> s. <br />