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----42/29/200,6 16:06 2094683,233 EHD PAGE 03 <br /> IFIED PROGRAM_C NSOLTDATED FORM N R; <br /> FAC M: <br /> UNDERGROUND STO CsE TANKS- FACILITY tl {lv'( ,,n <br /> p$c Pec site) t�'`� <br /> TYPE OF AC TION ❑ I NEW SITE PERMIT ❑ 3.RF,NEWAL PERMIT CHM <br /> CHANGE OC MpORATION T NENTLYCLDyfD SITE <br /> (Ch.:4 oiw dem Doli) ❑d,AMENOED PERMIT L].- m Tq <br /> ❑ i.TEMPORARY SITE CLOSURE URE <br /> roe <br /> 1.FACILITY I SITE INFORMATION -2 S U Ill b Z IC, <br /> BUSINESS NAMEcs,mt,trgaurY NAMEwOEAWka Ewktn A•) 1 PA 1D3 [Do <br /> P Od I' <br /> NPJ ST CROSS STREET ACLLITY WNETi T P ❑a.LocAL AGENGY/DISTAICT• <br /> dotI u 1..CORPORATION <br /> SU5INUSS ❑ 1.GAS STATION ❑ FARM^ LT+•MOIVIOUAL ❑3.STATEcOuNA AGENCY' <br /> TYPE ❑ CONhmtC ❑4.STATE AGeNCY• <br /> ❑1.DISTRIOUTOA ❑d.PROCESSOR G OTXE dp) ❑1.PARTNERSRIP 103 <br /> ❑7.FEDERAL AOENCY- <br /> TOTALNUMBER OPTANKS V facility on Indian Rnmation of •It..,of UST is a pAlitayemy:nnm<of R�pervisprofdivuien,:onion o.ol4u which opar.... <br /> REMAINING AT SITE imsDDMs7 <br /> ^/ ftUST(Thi:is rhe contact pmon F«ds tank tttwdt.) <br /> (t <br /> •p• Q Yn A .a1 O rod <br /> 11.PROPERTY OWNER INFORMATION <br /> F TY OWNER NA'.Es - .at PHU ^/Qdos <br /> osfi� -1 0 3! 0 <br /> MAILING OR STREET q RESS <br /> Z y (t - ®� np <br /> Cr II A .0 ZIP CODE �, r✓ dlc <br /> PKOPISKIYUYPL 01.CORPORATION 22.INDIVIDUAL 04.LOCAL AGENCY/DISTRICT ❑4.STATE AGENCY <br /> 113.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> 111.TANK OWNS INFORMATION <br /> T OWNER NAME •w PTIO.NE dl1 <br /> C C��/ 3 - O v <br /> LING OR STRFPT ADDRESS dla <br /> SIA.L.(�(�"� <br /> CIT .n STATE / at <br /> TANK OWNER TYPE ❑ 1,CORPORATIONd INDIVIDUAL ❑4.LOCAL AGENCY IDISTRICT ❑6.STATE AGENCY d'p <br /> S.PARTNERSI@ ❑ S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> "TY(TK)HQ 44• Call)(916)323.9669 if questions ari= 41 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHODW QISELF4N$URFD ❑d.SURETY BOND ❑ 7.STAT'EfUND ❑ 10.LOCAL COY(MECI•JANISM <br /> ❑2 GUARANTEE ❑5.LETTER OF CREDIT ❑ E.STATE FUND 6 CFO LETTER ❑99.OTHER <br /> ❑3.INSURANCE ❑6.E)ORi PTION ❑ 9.STATE FUND k CD <br /> VI.LEGAL NOTIFICATIOAND MAILING ADDRESS <br /> O,ck one bncumdk.0 which addwD ahoWd ba mcd for kW nofillcwion:and medln;. I,FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER -11 <br /> IsF9 msdhcetwnr Md rating wjU be sew to the tank won tank»baa 1 ar T i1 ehoekCd. <br /> VI .APPLICA R r SLGNATUXE <br /> Cirtl,lm'onJ« <br /> mfydwdtc cinfpmtwfon proHdea ht•ein is eve and secwueu Yw Veit of my know edge, <br /> SI A OF APPLICANT DATE d3. ONE •u <br /> !- 3 -07 2 9 - �c <br /> NLICANT)Print) ... 11 'Lt •17 <br /> P� to S sf.�! R "V2 'ems <br /> STATE UST FACILITY NUMBER(P., usoM) d» k99EUPGRADECERTIFICATENUKMR(Paldueeds) d-'P <br /> 11 1990.CnmPlianl'1 <br /> UPCT'(1/99 revised) <br />