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UuLFIEO PROGRAM CONSOLIDATED R>1 <br /> ,� II <br /> i ..� _ TANKS <br /> UNDERGROUND STORAGE TANKS — FACILITY <br /> �%14" 3 <br /> a ,aye par r.;3) <br /> ^SPE OF ACTION [' I NEW SITE PERMIT r 3.RENEWAL PERMIT r 3.CHANGE OF INFORAU- ea <br /> CN fS f oa - r 7.PERMANENTLY._OSEO SGE <br /> cc%: Ic weaem only) � 4AMENOEO PERMIT a ..only) ra.TANK REMOVED a� <br /> r i.TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION 1 qq <br /> I aUS;NES NAMIEt5 NAME or 08A-Coeq 3osness Asl 3 FAC.L:TY'.Oa I "1 I <br /> .AC:LITY OWNER TYPE <br /> i NEAREST CRO a _ L]1 � r a, LOCAL AG'cNCYl015TRICT• <br /> L =RPORATION [- S. COUNTYAGENCY- <br /> 3USINESS TYPE I GAS STATION r 3.FARM r 5.COMMERCULr.2 :NGMOUAL I [•i. $TATE AGENCY' <br /> 2.OISTRIBUTOR r A PROCESSOR r 6.OTHER 3. ?AATNERSHIP [- 7. FEOERALAGENCY- <br /> +D7 {+ <br /> pTAL NUMBER OF TANKS s'acaty an Ineun ResarvalKm a 'Y o�+ner of US s a ay <br /> REMAINING AT$RE �t w9'Y4sT �SCn.SeGan or'--trCe'vngl eoe/attl x`a UST` //) CtT.s u me mnrac arson lOt In Ixvc ecxcsl <br /> 4C+ rYes fw a05 •,06 <br /> Ii.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNERNAME +07 HONE +08 <br /> �un�� i3/�R��K3A t� 11E /�✓/ aoq q77-took <br /> -MAILING OR STREET ADDRESS + A612.6,*/A4 µ/,f Va�- <br /> STATE a:I I L1�Oi�O <br /> PRGPERTY OWNER TYPE /K3. <br /> C,,Y2 .NOMOUAL C a. LOCALAGF4CY104tICT r i. STA—..AGENCY 113 <br /> r CORPORATION K7 PARTNERSHIP r S. COUNTY AGENCY r 7 FEOERALAGE.NCY <br /> III.TANK OWNER INFORMATION <br /> 1 .tV/a � _ ./� PH4tONMEE -115j, <br /> T}NK OWNER NAME al+ "T�' 1 tkt:�, I�/Ylb //I_-i / 'V/�I/M4�1 � O'vI T��` �✓�� <br /> MAILING OR STREET AOORESS {/�/ 16 <br /> s17 ATEmB I LIPCODE +19 <br /> $-fOG,k-To/J I C/Y 1 07 <br /> TANK OWNER TYPE ffr--II2. INOMOUAL r a. LOCAL AGENCY I OISTRICT r i. STATEAGENCY +20 <br /> r I CORPORATION Y-3. PARTNERSHIP r 5. COUNTY AGENCY r FEOERALAGENCY <br /> SEE <br /> 'r(;TK)HQ 4 14 Utril/I /I/I Call(916)322-9669 it questions anse - -I <br /> I1 J P�'TRt11 IIM IICT FINSNf9G13E <br /> !NOICATE METHOO(5) r 1. SELF4NSUREO r a. SURETY BONO r 7. STATE FUND r 10. LOCALGOV.TMECHANISM ` <br /> r Z. GUARANTEE r S. LETTER OF CRWrr r 3. STATE FUND d CFO LT.R r 99. OTHER: <br /> r ] INSURANCE r6. DEMP ON r 3 STATE FUN03 CO <br /> nTt=irA <br /> Chau ana lwa m.loieate wnlm aaarass sewn os uM for'a9v MI16pIK.M am maJ rI. FACIUTY r '_ PROPERTY OWNER r 3. TANK OWNER - - <br /> r e I e eCl <br /> CMmTAtwn: 1 Fart y Inst Ne inform aNVCb her .s wa arla aoaaau m Ne east of mY v�o.•vaga. <br /> SIGNATURE OF APPLICANT I DATE +24 ( PHON 7 a25 <br /> NAME OF APPLICANT(Fnm) 4251I 7r.E OF APPUCANT + T - <br /> 004TATE UST FACILITY NUMBER+.For:ow tw orvr7 +261 '998 UPGRADE CERTIFICATE NUMBER frd.aCL'+CWIW +29 <br />