Laserfiche WebLink
�IFIED PROGRAM CON SO LIOATEORM <br /> �3Ial,I�T N© <br /> ©KS <br /> UNDERGROUND STORAGE TA KS - FACILITY •one page pe site) <br /> :I�05/8,�9 <br /> it pa' <br /> [ ? RMANENTL CS 7 SI <br /> [3.RENEWAL PERMIT [ S.CHA.YG'c OF INFORMA.•CN ISPe Ifrewnge [ d.TANK REENTLY <br /> ^rvE OF ACTON [ 1.NEW$ITE pE.RMIT wy vse MGVEO <br /> wiy) <br /> ICtxrane item CnlY) [ 4 AMENDED PERMIT [3 a7ORARY SITE CLCSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUS�YE'aS NAME ISame as FACILITY NAME w OaA-OCeg Business As) <br /> �— DO <br /> FACILITY OWNE0.TYPE [ a, LOCM.AGENCYIOISTRIC,T^�\ <br /> N $T CROSS FEET"T4401 s [ 1. CORPORATION [ 5. rOUNTYAGENCY' <br /> �1 [ S.COMM ERC:AL r 2. �NGNIOUAL [ 3. $TATE AGENCY' �JI Qac <br /> BUS• <br /> ESS TYPE [' t.GAS STATION .FARM [ 3. PARTNERSHIP I r 7. FEDERAL AGENCY' ✓ i/02 <br /> a PROCESS16.OTHER <br /> [ i DISTRIBUTOR [ OR 403 <br /> ^t,..ner°f UST's a�Ic agenen name cr w°erna°t w <br /> s:ryp Cn Itaun Reserramn w seewn w Crfira wnrtt Cnetvm a:e UST. <br /> TOTAL NUMBER OF TANKS atasCanas7 Rhu amafLttt'aC:Petantt fat me unxrxlrts) <br /> REMAINING AT SITE 1 a06 <br /> a0a [Yes <br /> 45 <br /> II.PROPERTY OWNER INFORMATION PHONE aDe <br /> P PERTY OWNER NAME 47 <br /> MAILING ORST^o tA0ORE55 <br /> fl' V I$TATE a:� I LIP C0��2� I <br /> CITY <br /> a13 <br /> [ a OIAGcVCYl015 RIGS <br /> NOIVIOUAI [ 9. STA.cAGENCY <br /> G <br /> pRCPERTY OWNERTYPE [ 5. cOUNTYAGE.NCY [ 7 FEDERAL AGENCY <br /> [ =RPORATICN [ 3. PARTNERSHIP <br /> 111.TANK OWNER INFORMATION I PHONE als <br /> ,At OWNERNAME 114 <br /> MAIL. GO 5 EI ADDRESS .16 <br /> 1 I $TATE ZIP COMAE t5 <br /> [ a, LOCAL AGENCY 106-3,IC; [ i. STAic AGENCY 120 <br /> INONIDUAL [ 7. FEOE.RALAGENCY <br /> ANK OWNER TYPE [' S. COUNT'!AGENCY <br /> [ I CORPORATION [ 3. PARTNERSHIP <br /> CCC <br /> TY TK)HO 4 a I I I I Call(916)322-9669 if questions apse <br /> oT• TMECHANISM <br /> 7. <br /> :NOICATE METHOO(S) [ 1. SELF4NSURED [ 4. SURETY BONO <br /> [ 5. r ct'TER OF CREDIT [ 3. $TATE FUND d CFO LCT.R [ W. <br /> T <br /> Z. GUARANTEE [ 9; STATE FUNO 3 CD <br /> [ 3. INSURANCE [5. cMmFr ION <br /> c [ 3. TANKOWNER <br /> f FACILITY [i ?0.0PER7`.'OWNER <br /> aw b Cey300 f Opal xk <br /> CL.ewt 740E G I ID M°°t n <br /> l,qLa <br /> ESIGNATU <br /> rtRyNal Na inlCrtnatpn crvanePeme Cast of mY M'e`^°°S° 424 I ?HONE <br /> ]ATC F APPLICANT T O_--- T <br /> F CANT fpnn0 <br /> ejel "r-B UPGRADE CERTIFIGTE NUMB ER IFV,c us°Cn1Y1 .t29 <br /> iTATE UST FACILITY NUMBER(Fw local useCM'1 <br />