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UN c0 PROGRAM CONSOLIDATED F RM \ II <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> case _ :t <br /> ,iIC T.PERMA.rNTLY os=_o si-=_ <br /> .RENEWAL PERMIT r i cIa NGE Of NfOPMAT:CN(Soeat/narge- j- a.TANK REMOVED <br /> {o <br /> ^PEOF ACTION r1.NEW SITE PERMIT ] yy ase a <br /> fG„as one item aatil r t AMENDED PERMIT _.,1PCRARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION I I I I I I c <br /> AOUTY'0 a I I I <br /> I du EsS NANtElSama as FACILITY NAMEu08A-Coag 3t„ness A,) ] In p00-7/qLY <br /> S:N <br /> ✓"I`/ C a, �:CT <br /> wl l-t FACiLtTY OWNER TYPE LOCALAGENcYIO15 <br /> E: BEET 41 / es y_ C CORPORATION COU:n"AGENGY' <br /> NRESTGROS53T C i. jTATEAGENCY' <br /> ( tfPeCla�i�' 2 �NGMOUAL <br /> r 3.FARM [ 3.CGMMERC AL aARTNERSHIP r /, fE7 ERAL AGENCY' :2 <br /> 3USINESS TYPE I.GAS STATION r S OTHER r 3. <br /> [ L OIST0.1BUT00. <br /> [ +,PROCESSOR 43 <br /> Y awrir at U5T'a a abler agene!name a waervuar at <br /> a y ,Y an 1rc R,SS rvam.w �� stom uVS=wnKst axratm as UST. <br /> TOTAL NUMBER OF TANKS atuaana,' fTh,e,e ce move aer,anlar Netrl <br /> REMAININGAT STc 46 hA <br /> 2 <br /> it.PROPERTY OWNER INFORMATION PHONE ice <br /> ?,A 3ID � la3 <br /> PROPERTY OWNER NAME 47 <br /> 68P1t X01 . <br /> MAILIN OR EET AOORESS 1 ' es ISTATE ILIP G00° At2 <br /> lll� fslrt� J V�v✓ CA51Jl a%,LAo <br /> c:r. ,ter <br /> [ a.NOMOUAL LOCALAGc.NCYIOISTR:CT �. T FEDERAL AGENCY <br /> PROPERTY OWNER TYPE [ i. COUNTY AGENCY <br /> `yr. CORPOPATICN [ 1 'PARTNERSHIP <br /> III.TANK OWNER INFORMATION IavoNE ,te <br /> TANK 3W66NERNAyyM�aE ,ter i <br /> MAIUNGO�R`JTAOORES5 at6 / <br /> f -te i LIP CODE atS <br /> � C <br /> c:r +Ir [ <br /> �� i. iTA cAGENC a10 <br /> [ a. Cou.TYG GFYIOISTRiCT [ . FEOERALAGENCY <br /> [ L INOMOUAL <br /> 'AHK OWNER TYPE <br /> [ j. COUNT'!AGEvCY <br /> CORPORATION [ ]. PARTNERSHIP <br /> ccc r <br /> I I I I Call(916)112-9669 if questions apse <br /> T((TK)HQ 14 <br /> P r RF Pfa CIRII ITY �' 10. LOCAL GOVT MECHA.N15M <br /> P r T. STAT'UNO <br /> :NOICATEMETHGOW r 1. SELF JNSUREO C •. SURETY BONG r j STATE FUNO&CFO LETTER <br /> Cis. OTHER:— <br /> [' 5, LTTEit OF CREOR <br /> r 2 GUAWINTEE r r 3. STATE FUND&CO <br /> e. �APnON <br /> ]. INSURANCE <br /> TANK CY-NE”' <br /> Gwx ana vas ro nalau wnrcn aaUeaa slbul0 rH Ix.In vagal naaAcatbns ana ma:iq. <br /> -k*,!. FACILITY �P0.0PERT`!OWNER <br /> air Ufimmn,orb marlin ,wnl b< em'P me rxv a.r�er°^1°as oz t err'� CmIXea. <br /> ) o <br /> a I.eren o we ana acarau ro Ole Ee4 of my +KK'Fie- ata PH E '�a3 <br /> CMLIOm?. I C1mn'Nat Ina in/IXmatian ! 7A, l ` 0") J <br /> SIG, rUR F APPLICANT <br /> x251 TL°�� •n <br /> MAMF�•JF;tP_ . A� <br /> µ(ft !V'W a251 'y UPGRADE CERT.F:CAENUMOERIF". +se mlYl a29 <br /> STATE U5T FAGUTYNUMBERfFaracaln a -) <br />