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Jul 13 2006 6: 25PM Ra-age Environmental , Inc (SIP) 354-1786 p. 2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACEMY <br /> (one page per sitz) Page of <br /> TYPE OF ACTION 13 1.NEW PERMIT 0 3.RENEWAL PERMIT C3 5.CHANGE OF INFORMATION PERMANENTLY CLOSED SITE 400. <br /> (check arta item only) [3 4.AMENDED PERMIT(Specify dung,) off S.TANK REMOVED <br /> [3 6.TEMPORARY SITE CLOSURE <br /> NEW <br /> BUSINESS NAME(sameu FAcam NAME c,DBA-Dajata 11wince.A.) 3 1 FACHAT <br /> COWY REVEtJVE ANDtjECOVC� IDN Pill's <br /> NEAREST CROSS STREET 401 FACILITY OWNERT NCYANSTRICP 41C. <br /> SAS ToAlIV ET [3 1.CORPORATION jd5,COUNTY AGENCY- <br /> I- <br /> .%0E- --- <br /> BUSINESS Li ION 3.FARM 05.00MMERCLAL 4at 0 2.INDIVIDUAL ❑5 STATE AGENCY* <br /> TYPE El 2.DISTRIBUTOR 0 4.PROCESSOR X 6.OTHER [13.PARTNERSHIP [3 7.FEDERAL AGENCY* <br /> TOTAL NUMBER ;facility wIndian Reservation 40 *If owner of UST is n public egmcy:name of supetviw[of division,section or Ona <br /> REMAINING 4 r tintst lands? ofFv*which operates the UST. (This is the contact person fin the tank records.) <br /> I Yes ;2(ND Ms, KERRY wAI;;oN <br /> II' PRly-w"77-64"W" <br /> PROPERTY OWNER NAME 1107 PHONE 408 <br /> tQV14TY OF SAN TOAG%I1K oo-q) 168-3675 <br /> MAILING OR STREET ADDRESS 4W <br /> 1122 E. 5COTTS AVIiNVE <br /> CITY 410, 1 STATE 41 L. Zip CODE 412, <br /> GA <br /> S-rorlivTO N A9r.I o S <br /> PROPERTY OWNER TYPE Lj I.CORPORATION Ej 2.INDIVIDUAL Lj 4-LOCAL AGENCY I DISTRICT U&STATEAGENCY 413 <br /> ❑3.PARTNERSHIP 05-COUNTY AGENCY [17.FEDERAL AGENCY <br /> A- <br /> TANK OWNER NAME 414. PHONE 415. <br /> COUNTY OF SAN JOAGVtN ('z 0.9) `}68-9623 <br /> MAILING OR STREET ADDRESS 416. <br /> 1112 E. 5COTT5 AVENYL <br /> CITY 417 STATE 4111, ZIP CODE 419 <br /> STOW-ON - C-A 95205 <br /> TANK OWNER TYPE L-j 1.CORPORATION 0 2 INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT U&STATE AGENCY 4m <br /> 0 3 PARTNERSHIP 5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV. BOARD OF E1Q(JAMAtIt)P! <br /> FR <br /> TY(TK)H -44- Call L916 322-9669 if questions arise 421 <br /> V. <br /> INDICATE METHOD(s) 0 1.SELFWURED 0 4,SURETY 13OND [3 7 STATE FUND E3 10 LOCAL GOVT MECHANISM 422 <br /> [I 2.GUARANTEE [3 5.LETTER OF canorr [3 a.STATE FUND&cFo LETTER E3 99.OTHER: <br /> [13.INSURANCE 0 6.EXEMPTION 0 9,STATE FUND At CD <br /> Cbeckorm box to indicate which address should be used for legal notifications and calling, <br /> Legg nniacatiouc and aciahngs will be sent to the tank owner unless hox I ver2 is checked. [IL PACIUTY 02. PROPERTY OWNER 03.TANK OWNER 423_ <br /> Certification: I certify that the information provided herein is ace and axvurige to ft Ing of my knowledge. <br /> SIGNATMRE Of APPLICANT DATE Q4 1PHONE 425. <br /> NAME OF APPLICANT(Itkint) 426 TITLE OF APPLICANT 427 <br /> -ToSEPIA RAMC-L C*N$VLTANT r6lk TANK OWNER <br /> STATE UST FACILITY NUMBER 428. 1998 UPGRADE CERTIFICATE NUMBER(Ageney Use Miy) 429. <br /> (Sm Data Flemisial 1,above. <br /> UPCF Hw(wric,it(lf99)-1/2 http://" .isaidoes.org Rev.02/16M <br /> MISSION <br />