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ORM JZ��Jdy j <br /> 1F1E0 PROGRAM CO <br /> NSOLIDAT f <br /> TANKS <br /> 1 <br /> UNDERGROUND STORAGE TANKS - FACiLi <br /> {on pe a per site} <br /> r <br /> S.CHANGE OF INFORMATION(SoecifyUla^9e- <br /> r T.PERMANENTLY CLOSED SITE <br /> r 3.RENEWAL PERMIT r B.TANK REM D 400 <br /> ] NEW SITE PERMIT TE Iota use <br /> TYPE OF ACTION only) I Q <br /> (fix one item oNy) tl4.AMENDED PERMIT 1' 6 TEMPORARY SITE CLOSURE <br /> 1.FACILITY 1 SlITE INFORMATION <br /> I 3 FACILITY 10 9 <br /> E Same as FACS NAME or DBA B�sineas Asl �1_ <br /> BUSINESS NAM I J 11 / rt I- ', 7] 'i r q. LOCAL AGENCYlD1STRICT' <br /> _ ��J / o[ v � �C, FACILITY OWNER TYPE <br /> N,EgR�ST.CROSS STREP , 401 <br /> r t. CORPORATION 5. COUNTY AGENCY' <br /> INocviDUAL r 6. STATE AGENCY' <br /> r 1.FARM r 55.OTHER <br /> � r' 7. FEDERAL AGENCY' a02 <br /> BUSINESS TYPE r I-GAS STATION �J- r 3. PARTNERSHIP <br /> r 4.PROCESSOR403 <br /> r 2 DISTRIBUTOR name of suae�r of <br /> Is taatity on Inamn Roserrauan or 'tt t7wner d'UST ss a ouotit agency: les the UST. <br /> dlmion,saeto^or otfioe wnrC m open <br /> TOTAL NUMBER OF TANKS ttustlands7 {This is the contact Person for the tanK nacoras.] <br /> REMAINING AeSITE J <br /> \/ Yes ,o 405 406 <br /> IJ ll. PROPERTY OWNER INFORMATION PHONE 40e <br /> 407 <br /> �C <br /> PROPERTY 0WNE NAME <br /> LINGO STT�REEET ADDRESS C, <br /> /// STATE 41t ZIP C00 4t2j <br /> CITY ala <br /> 6. STATE AGENCY 413 <br /> INDIVIDUAL r a. LOCAL AGENCY r DISTRICT r'7 FEDERAL AGENCY <br /> PROPERTY OERTYPE r 1. CORPORATION [' 3. PARTNERSHIP r 5. COUNTY AGENCY <br /> Ill.TANK OWNER INFORMATION /1b <br /> PHON� <br /> TANK OWNER NAME 414` <br /> A;, y <br /> r� <br /> MAILING OR STREET ADDRESS 4116 c <br /> `� �} � )t S STAVE 418 ZIP CODE 419 <br /> r� <br /> CITY 117 <br /> /0 r r q. LOCAL AGENCY f DISTRICT r 6. STATE AGENCY 420 <br /> iNDFVIDUAL r 7. FEDERAL AGENCY <br /> TANK OWNER TYPE r S. COUNTY AGENCY <br /> r t. CORPORATION r 3. PARTNERSHIP <br /> TY(TK)HQ 4 4 - <br /> Call(916).322-9669 if questions arise <br /> v PET r7. STATE FUND I 10. LOCAL GOVwT MECHANISM <br /> INDICATE METHOO(S) I' 1. SELF-INSURED r 4. SUREETY 60140I'5. LETTER OF GRED99. OTHER <br /> 8. STATE FUND S CFO LETTER <br /> r 2. GUARANTEE r 5. EXEMPTION r 9. STATE FUND&CO <br /> INSURANCE <br /> Cr1eLk one Cox to inait�[e whitYr address should tle��far legal nptirimG0n5 and mailing. r 1. FACSLITY <br /> PROPERTY OWNER T' 3. TANK OWNER <br /> al npSir nuns antl maihn 5 will be sent tp the tank pwner unless hoz t yr 2 ii U+odted <br /> Ceneicatwn: I canify that the r)fcrmaWn Provided herein is[rue accurate to the best of my kno $eage. q2a PHONE <br /> DATE / n' <br /> SIGNATURE OF APPLI /(, ,-- C-- - <br /> 4251 TITLE OF APPLICINT / i 4 <br /> NAME OF APPLICflNT fpnnt) <br /> l'/ 428 t998 UPGRADE CERTtFtGATE NUMBER(,;:Cl.loci use aNy) a29 <br /> STATE UST FAGILSTY NUMBER(For bca+use only) <br />