Laserfiche WebLink
uo:3j 2094633433 <br /> FIFTH FLOOR 310 53 IZ-�'dCo <br /> D PROGM RACONSOLEDAFED F PAGE 03 <br /> TANKS <br /> UNDERGROUND STORAGE T <br /> ANKS - FACILITY <br /> TYPE OF ACTION '���'S/D `/'7(✓� <br /> Check on SINEW PERM <br /> �J (One page Pu site agc_o <br /> ❑4.RENEWAL PERMIT (9�-GHANG60F <br /> :.1': ❑6 AMBNDFA y SITE (Sp huge)change) 1NFORMATI'ON ❑7.P6RMAN CLOS <br /> 1 EMPORARY SITE CLOSURE ��. `R8,IANK , „ VED CLOSED oo. <br /> Item /" <br /> t (sere aPALTLy dAMa I FACII�TS'AS3TE I all <br /> or DBA >b�a e�amea A) 3. FACILI1Y ' „ , <br /> N <br /> AS <br /> T CROS ST T ID4 F� <br /> 40111. FACILITY OWNER TYPE 'jlir ii f . <br /> SINESS 1.GAS STATION ❑3.FARM W`• ❑ I.CORP ORAT)ON r4.LOCALAGENCY/DISTRICT• 4az. <br /> TYPE El 2-DISTRIEUTOR 4 ❑5-COMMERCIAL 403, ❑2,JNDIVIDUAL Q5.COUNTY AGENCY. <br /> ❑ .PROCESSOR G.OTEER ❑6.STATE AGENCY. <br /> TOTAL OF TANKS 464. 1s faejlliy on Indian Resctvation 4as. ❑3 PARTNERSHIP <br /> G AT SITE ❑7.FEDERAL AGENCY. <br /> or Trust lands? '1f owner of UST i9 a public a <br /> or <br /> NO office which operates tlk UST, (Thio is the ca� oq eecd <br /> mwn for,uPervisar of division <br /> ❑yes <br /> N <br /> 77�777 t. I�j✓m Q r c tank <br /> 'OPER-TI-1 <br /> ,a ea <br /> P O <br /> ) <br /> rc rya, <br /> P RTY .. <br /> T RTx i1W1VE,RXNFO r ;r. :',^ <br /> RMA�RQ� <br /> MAI ORSET AD wa <br /> S p . , <br /> O doa <br /> C 'y C <br /> 'M dos. <br /> U mo. STATE 4n. <br /> PROPERTY /1 ZIP CODE <br /> WNER TYPE I.CORPORATION J'1 412.2INDMDUAL 4.LOCAL AGENCY/ <br /> " , ,: , ❑3.PARTNERSHIP DISTRICT ❑6.STATE AGENCY du. <br /> ❑S.COUNTY AGENCY <br /> ,mr�p• ' ❑ZFEDERAL AGENCY <br /> T. , WNER N ETII 7Al�iK O,. , ::;. W1uERIl�tORMON �;: <br /> t41a PfIONE <br /> MAILM RS ET ADD - ais!: <br /> C 416. <br /> 417. STATE 419. ZIP CODE /^ <br /> TANK O R TYPE , �w 419. <br /> 1 CORPORATION <br /> 2,PARTNE AL •LOCALAGENCY/DISTRIC AT <br /> r : ❑3 PARTNERSHIP AGENCY .ST ENCY <br /> TW 14.I�: iF.i Ui' „ 6 DERAG AGENCY <br /> o. <br /> ❑5 COUNTY �7 FEDERAL A <br /> Q ALI�ATIOIK ITST STo Et- ACCOT3NTNCj1►�SER <br /> TY AQ 44 <br /> Call 916)322-96,,,,,, ueshons arise <br /> 96 4a1 , <br /> „ Y ETRpi EL[1VT UST. FfN 1iCP4TrRFS>0 OI3I$IBTLYTir <br /> INDICATE MEIHOD(s) ❑1 SELF II'ISTJR� ❑a.SURETY BOND ❑t.STATE FUND a . •: ' .. . <br /> 2.GUARANI2"6 []5.LETTER OF CREDIT 13g, Ei7ER STATE FUND&CFO LLJ 10 LOCAL GOVT MECHANISM <br /> ❑3.INSURA�CE ❑6.EXEMPTION ❑9,STATE FUND&CD [3 99 OTH6Re ..4xx. <br /> uld be reed fir le,nl nonficatS ,.., <br /> [Check oic x�tlott6aoaox led nithn hallbe eenf Oons end mailing O�`A,ND`1�r1>lIIFj�TG.,A.�b�S.SS <br /> 83 t to the Ink owner Q—=.box <br /> W.LEGAL L� <br /> y� _. ❑3.TANK , <br /> I m2is checked. ❑ ].FACILITY �i 2. PROPERTY OWNER <br /> /� OWNER 423. <br /> ; [ ekPMOE, Nl,SiGNrlfiflRFi,'',i; <br /> Cetbfieauon. 1 comfy that the mtbrmaaioo Provided herein is true and accurate to the best of my knowledge. <br /> SIGNA FAPPLICANT <br /> DATE d±4 SHONE <br /> L 4xt. <br /> NAME r (CANT(print)n_12 A O <br /> 4a" TI Z <br /> � TITLE OF APPLICANT <br /> aa, <br /> STATE UST FACILITY NUMBER(Agrvuve eery) q±g, cN16"p— L E'N�iNC—�� <br /> (See Data Element 1,above. 1998 UPGRADE CERTIFICATE NUMBER(A9engneeonly) <br /> 429. <br /> UPCF flwfwre-a(1/99)•lh <br /> http://ryww.Inidocsar{; <br /> Rev.o2/"o <br />