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UNIFIED PROGRAM CONSOLIDATED FORM 73 <br /> T <br /> V ANK/S <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) j <br /> Page _ of _ <br /> TYPE OF ACTION N NEW SITE PERMIT r 3.RENEWAL PERMIT .CHANGE OF INFORMATION(Soeary ohange- I- 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) '/k\' ��a wyy) r B.TANK REMOVED 400 <br /> [ a.AMENDED PERMIT <br /> r S.TEMPORARY SITE CLOSURE 3 <br /> I.FACILITY/SITE INFORMATION -rA 0 5/5 93 <br /> BUSINESS NAME(Same as FACILRY NAME m A-Dbing au .AS) ] FACILITY ID# <br /> /Q ► Q, �w 00/3375 <br /> NEA ST CROSSS ET401 Si//.- FACIIJTY OWNER TYPE r 4. LOCALAGENCYIDISTRICT- <br /> I it r 1. CORPORATION r S. COUNTY AGENCY- <br /> BUSINESS <br /> GENCY•BU ESS TYPE r t.GAS STATION r 1 FARM r 5.COMMERCIAL 2. INDNIDUAL [-S. STATE AGENCY- <br /> r 2.DISTRIBUTOR F 4 PROCESSOR6.OTHER r 3. PARTNERSHIP ] 7. FEDERALAGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is fatality bn moian Reservation or 'If ownm of UST is a p ohc eganq:name of suPemsw of <br /> REMAINING AT SITE wstance? division,section w office whxm bperetes me UST. <br /> (This Is me cmaact person torr me tank racams.) <br /> a04 rye. F No 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHON408 <br /> Q ( 4 " <br /> QJ J\ <br /> MAILING OR STREET ADDRESS 409 - <br /> CITY 1D G / ..TATE + all 21P 00 412 <br /> PROPERTY/\OWNER TYPE NDNIDUAL r 4. LOCAL AGENCY I DISTRICTf�- r S. STATEAGENCY 413 <br /> r 1 CORPORATION [ 3. PARTNERSHIP r 5 COUNTY AGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> ,5 aoievu� <br /> Q <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 P CODE 419 <br /> TANK OWNER TYPE INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 420 <br /> r t CORPORATION F 3 PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) F 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND F 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r S. LETTER OF CREDIT r S. STATE FUND&CFO LETTER F 99. OTHER' <br /> r 3. INSURANCE r S. EXEMPTION r 9. STATE FUND&CO 422 <br /> Cheri one bok to Micate which address shook be used for legal notJwdons and mailing. r I. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 ! <br /> I d! Il basent tometankmirngrymessbox I or2- Uadkad <br /> VII APPIjrANTQ11M_%1A�sss= <br /> CaMKation: I p rfy mat 61e a ormatan provked heroin is true and sm ate tome best of my knowl"e. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(Print) Q5 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fctr a use on)y) 426 less UPGRADE CERTIFICATE NUMBER(Forkcal ties,only) 429 I <br /> I <br /> .sRoo01659s - rr- ol <br /> I� �o Ck�n favi-� <br /> To b r e Yta a v� �, �' ! -71101tq <br />