Laserfiche WebLink
0 0 <br /> iTNfFTF.I]PRor.RAM C ONSOI ITMETI MItM <br /> TANXS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (ona;3zcpersicc) <br /> SYS OF AO ION1. NFW SITe FEFI✓Tr 1.RENIEKAL FERAT CJ S.CFANCT OFT, ORMATION 7.PEAM1hNLPpTLY CI 03s3A SITE <br /> (Chuck cow 14—only) C 4.0-msmz)ho PE wT tpc&Y,ehsugp local ut�oab —© B.TrINK A i�fAVIIQ <br /> ❑b.:EMPORARY SNt M07JX! a oa <br /> I. FACE TCY I SITE INFORMATION <br /> �USIN>3SSNAM.of9araaeswCCtitYNhht60i08/—AV�AS :.w.ennl 7 'FACTL(TYICk <br /> • i <br /> b awl U <br /> NEARPSTCACJSSSTRPEC ict FACEC.[T"f OWNER=B 4. A /F�FSTRICT <br /> di-R O'F.CORPOPAVON q 5-COUNTY kGENCY• <br /> W&TNEas _0..4 gTATtQN 3.FAlkM 3. CoNmmcfAL a 2.TlV1lIVIDFSAL ❑G.STATS AGENCY'S <br /> TYFE ❑z.DISTRIBUTOTt ©4.FROCE95GR❑S. onmR 403 ❑ 3.FA.RTNEAsI•LIl' ❑7,PF1)fiIUtLACrhFCX 6M <br /> TOTAL NUMB OF TANKZ 16 C ilitl•oo Iat"^Reacrvst4aa ar •iCowner oP UST 3n iy w ich <br /> RENIA2FtNGtiTSITE ht3atLtnts4�y(� opeiraatr3 UST(Th9c 3tbcoo-taotpcaoafarthotnnkr�.tdr) <br /> 401 ❑ t'Y6 L' "" kL5 4C4 <br /> IL PROPERTY OWNER TNTF'ORMATION <br /> PROPERTY OWNER NAME PHONE 1f 6 <br /> 14RVQ OIL MEET ADDR,7$S V-C4w <br /> - 4034s <br /> L.i 33u STATE 1 ZIP CODE aU? <br /> ire ea7e sr <br /> pRlJPER 0 ER TYPE CDFUPORATION INOtVTDiJAL4.LOCAL Ara :VcY i D197RICT 06.97ATEAQENCy <br /> D 3.PART:=SNtP 3.COUNTY,ZLNCY ❑7.FFDERAL xG91 CY 419 <br /> IIL TANK OWNER INFORMATION <br /> TANKOWNaNAM, Z 414 P WF: 411 <br /> Mwma:aemmrout 3t� <br /> OR ST77X36I'AADRjsS$ 410 <br /> i <br /> .C7• �r1G (� <br /> �Ty 337 STATE UC PIP CODE 41Y <br /> Tl�NlC owl7VTwr; I.O07ePCRIT ON �.�nlvml;AL a.D3CAL AGP—NC Y/FrLSral <br /> p 3_P.ARTNERSHIP ❑S_COUNTY AOENCY 7,FEDERAL AQUN+;Y <br /> TV.BOARD OF EQti.1LMtTION USI'STORAGE FEE ACCOUNT NlJIVIBER <br /> TY(TK)-H 44• O 1 45 0 14 1 Call 91)32-9669 if i;stiens arise 44 <br /> V,?FTROL1EI 114 UST FINANCLkL RESPONSIBII'ffy <br /> TDICtiTB�I>TEO>r(E) SELF-FNSURTI7 �d,$L-,�UTY 30IvP �7.97hTE PLTID © IO.LOCAL30vTmECH 1N19M <br /> ❑2.GUARAN-rigA ❑S LarrER OF C1i"'DIT ❑&STATE FUND&CFO LETTER © 99,07 HaR <br /> ❑3.I:SVJLANCL- ❑6.IX&14PTION ❑9.STATE FUND&CD <br /> VI.LEGAL NU'I'II1'ICATION ANI3 MA111NG ADDRESS <br /> ChcCKOdc LWc IP iadi[nw wilt acldre�xlmld ba uwoct liar 1.•ilneii!lwtiom nad rtul]iat3. <br /> Leal aotitiaotloasandmaditgtwlii:ccoetto3b1:t .l•owncsm: sboxIor--Fs,;0tk=L ❑ 1,FACILTry ❑2. PR.Q-=YOWNER EKTAN7:f)NNErl +=� <br /> VYT.APPLICANT SIGNATURE <br /> CeRitycudrn:-I ';yfhat7b.einfi3nnadtnproridedhmainiatSUepttdacewAktod3ub4stofmylegwkde. <br /> SION ATURL',F 1CANT DA <br /> f � Z!/C�� +%` PEFQhP <br /> 2/� �� 525 5$S� xt�2' <br /> p" ) TI—LL FAP LtCANT <br /> h1TE Li FACIL Z;&,m�R(Fat acal.Featy) ♦:� 1194E UTORADL CBXMF°CATI!14UMB21t mlm:l my) <br /> UPCF(1199 rcviscd) 3 i FozxnL-rIy SWRGS Form A <br />