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I <br />UPCF Hwfsvm�(1)99)-12 httpd/www.uWdo org Rev. 02/16/00 <br />PROGRAM CONSOLIDATED FO• <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(Page Pe site) Page_cf_ <br />TYPE OF ACTION 1. NEW PERMIT ❑ 3. RENEWAL PERMTT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOS® SITE <br />(Cbwk . esm �) <br />40Q <br />06. TEMPORARY SITE CLOS His) ❑ 8. TANK REMOVED <br />L FACILITY/SITE INFORMATION <br />BUSINESS NAME(sm. FA(,-aIfY NAM2 e. Dm- Dong Es. M) 3 FACILITY <br />4 I N O CAl M A Rltt- f ID# F A U 1 0 01315 9 l <br />1. <br />NEAREST CROSS STREET at. FACILITY OWNER TYPE U 4. LOCAL AGENCY/D15TRICT* <br />4oz <br />❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />BUSINESSUSLUASNIXIIQN U3.17ARM 5. COMMERCIAL 4m ® 2. INDNIDUAL ❑ 6. STATE AGENCY• <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER ❑ 3. PARTNERSHM ❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS 4a. Is fmility m Indim Reservation . • If owner of UST s a Pbhc age Y o of np.w of div w. sstion ar <br />REMAINING AT SITE <br />'ai <br />or boat lends? offices whchopsate the UST. (Ths s 0. oafam peram far the taok nm.dr.) <br />❑Ye ®No <br />IL PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME �_ PHONE <br />YY t u 2oq 931- 5L($ <br />wa <br />MAE,IN OR STREET ADDRESS <br />Z O W Zip <br />4oa. <br />CITY ata STATE 411. ZIP CODE <br />STOGKTb 9 5 ZO to <br />47z <br />PROPERTY OWNER TYPE 1. CORPORATION 2 IIDIVIDUAL 4. LOCAL AGENCY / DST 1CCT 6. STATE AGENCY <br />413. <br />❑ 3. PARTEIERSEI� ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />ELL TANK ONEINFORMATION <br />A <br />TANK OWNER NAME AntiPJ--iT SING 414. <br />PHONE <br />413 <br />zoo 931 -5�{8� <br />MARLING OR STREET ADDRESS <br />8Zo3,5-Hwy 2-G <br />416 <br />CITY 437. <br />STbcK-r-ni.t <br />STATE C jq ares ZIPCODE <br />RSZob <br />439. <br />TANK OWNER TYPE 1. CORPORA TIDN-2IIDIVIDUAL ❑ 4. LOCAL AGENCY/DSTRICT [16. STATE AGENCY <br />Fl 3. PARTNERSH� 5. COUNTY AGENCY 7. FEDERAL AGENCY <br />4m <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY K H 44- Call 916 322-9669 if hest ns arise <br />.zl. <br />V. PETROLEUM USP FINANCIAL RESPONSIBEL.TTY <br />INDICATE METHOD(s) 13, . SRLF-INS4)RED ❑ 4. SURETY BOND [9 7. STATE FUND ❑ 10. LOCAL GOVT MIi.CHANISM <br />El Z 0 5, LETTER OF CREDIT jZ8. STATE FUND a. CFO LETTER <br />432 <br />❑ 99 OTHER <br />INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND d CD <br />VL LEGAL NOTIFICATION AND MAILING ADDRESS <br />Chedr om hoz fo s>dk.ro whch address should w sW for legal wtjfi fine evd maRivg <br />Legal nuti6catiov end mmhW will be sem m the tack owam udes bmr I or 2 s clucked ® 1. FACILITY [12. PROPERTY OWNER ❑ 3. TANK OWNER <br />423. <br />VII. APPLICANT SIGNATURE <br />CeThfrat I oetify that Iba mformtim pmwided hsain s tn. and a is W the bet of my kwwbdge <br />SIGNATURE OF APPLICANT DATE 4z4. PHONEc <br />4zs. <br />`` <br />2-0q 1 � <br />v <br />N OF APA.ICANT (print) 426 TiTI.E OF APPLK;ANT✓ <br />AMA <br />4n. <br />rQ awt.IErt <br />STATE UST FACILITY NUMBER (Assearyw..may) 4- 1998 UPQ2ADE CERTIFICATE NUMBER (Agency w.e eNr) <br />(Sm Data Elemmt 1, above. <br />4z9. <br />UPCF Hwfsvm�(1)99)-12 httpd/www.uWdo org Rev. 02/16/00 <br />