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04-03-2001 08:29RM FRckl — <br /> TO . 368:851 <br /> '° =UNDERGROUND <br /> UNIFIED P ROGRAM CON$000ATED FORM �� •�� <br /> r <br /> I 3II� <br /> STORAGE TANKTAS — FACILITY <br /> ;CIM,69t,COR dl! <br /> rTE DF ACTION r %.PeRm,.NENTLY CLOSE`SITE <br /> fCAecA ane iRr ntiyl ��.4eY/SI-e PCRmr raRENeYrAL PERMIT TaCF?NGE OF PSOPAWTION tsOsdn='HnBe• rA TANK REMOVED 4CC <br /> PEI •e• ..� I <br /> r AMENDED Ptra' er �W� I <br /> T 6 TEmR0RARYS17SCLOGORE <br /> I.FACILITY!SRC INFORMATION u <br /> SOVIIEBB NAME(6eme m'A"-- <br /> Prem <br /> ACIA MAL1E ar DSA D^°e BPw..A.! 3 FAC LI IDs '" <br /> Prem Dor 433 W. Scotts Ave . Stkn GA N/ <br /> NEAR"66•CET <br /> 10665tgE T 4C1 FACILITY OIM.ER TYPE r a. LOC.ALAGENCf.MISTRICT' "7 <br /> L • :' I. CORPORATION r S COUNTY AGENCY' 1 <br /> "NESS A F'`h GAS STATION r 2.FARM r 6 OCmmdACIA. i 2. L'ADNlIDUAL r a. STAT£AGENCY' <br /> r 2 0 STFum OR r A PROC£sSCR r 6 cTNP. T 3 PARThmR lP r 7. FEDERAL AGENCY' GC2 1 <br /> -03 <br /> TA,NUNS R OF TAWS Is IF En Mw RedATmalm a 1f awimr 4UST aa(uv'E aBveT.rune vd.uverv.a PI <br /> RP•+vNWG AT SITE UVWena? dnusn,.eeivn ar OSI,~VWEI"UST. <br /> ;TR!If ma•A ON,. NY PV1W romC..I <br /> ADA 2 rYa X,, -'I <br /> — AG <br /> 11.PROGERTY OWNER INFORMATION <br /> fiR VME NAME JC7 PHONE ADB <br /> Prem Dor (256)435-8701 <br /> mAn.INc 6 e ADDgess ioa <br /> 2675 Kings Gap Mountain Rd. <br /> j TATE ill 9P CODE 411 <br /> Piedmont <br /> R. DY.I.ER TYPE r 2. RADMOUAL F �. LOCAL AGENCY I D16TRICT r 6. 37ATEA=NCY 113 <br /> R r 1. CORPORATION 3. PAjI I•ERSFW r i COUNTY AGENCY r T FEDERAL.AGENCY <br /> �i <br /> III.TANK OWNER INFORMATION <br /> HL <br /> HA <br /> I MAILING CR 9TRBBT R£K Al <br /> 1� 2675 Kings GaI2 Mountain Rd. <br /> ` A' Alabama 36272 <br /> Piedmont , <br /> . P r 1. WOMOUAL T 4 LOCAL AGENCYlOISTAICT r 6. STATE AGENCY dTJ <br /> p 1. CORPORATION r 3. PARTNERI r s. ODUNTY AGENCY r 7. FEOBRLL AGENCY <br /> Tv(T))y0 a A Call(816)322.8668 N gU141 s arselawI <br /> ie 1 <br /> BUM.A METIII r t. seLFLFISURED r A. i R&TY BONO y T. VATe FN T 10 LOCAL OOV+T MECNAN!3M <br /> r 2 GUARANTEE r 9. LETTER 0i CREO7 r 4 STATE FUNDS CPO LETTER C 69 O ER' <br /> AN <br /> T 3. Y18 PANG r B. CAEAIP' ON r 9 STATE FUNDS m <br /> ChAI Yn ,w 1y Y IM AAlfeef yr:+m auyed.ro lapl n vetvn.rdm r 1. FACEITY r P000RTYONNER r 3. TANK O'A'NCR -M <br /> U11 ADrA It-ANT AlIMINATI 129 <br /> Dm1Na101f�. I NRnrmLTe- ie Fltl am.rae LPN dmy <br /> T>Jae Q. TE a.S7U 12A PNdNc _ nE <br /> NnPE <br /> OFIV IAse F PL. T <br /> L � � �-- <br /> STA LL^INWSBSR( «r wP a+N na 1Bve UPCMCE <br /> CERTIFICATE NVMBCTIAN&AII aMY! '0 <br /> 5 FOrcne,lY SWI FerT,A <br /> UPI(V99 revised) <br />