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Lo EO PROGRAM CONSOLIDATED FO _ <br /> UNDERGROUNDS���G� TANKS - FACILITY 71r� <br /> one Dave Der te) Y <br /> — Papa _ of <br /> TYPECFATION C 1.NEWSITE PERMIT ❑ 3.RENEWAL PERMIT <br /> (C.lep waimm aMy) .E 1 CHANGE OF INFORMATCN(SA..ff ,ys_ ❑ 7.PERMANENTLY CLOSED SITS ) <br /> Cl 4.AMENDED PERMIT local ose wM Cl S.TANK REMOVED // A'IVNJy/ 40 <br /> C A TEMPORARY SITE CLOSURE <br /> L FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or CBA•0p SOsneee Asl 3 FACUTYIOV I 1 <br /> vial <br /> PAC: <br /> NEA REST{Q"S�S STREP 41 UTY OWNER TYPE ;�q, LOCAL AGENCYR]ISTFIILT <br /> L - ) ��1� ❑ 1. CORPORATION 05. COUNTY AGENCY- <br /> BUSINESS <br /> ❑ 2 INDIVIDUAL <br /> ❑fl STATE AGENCY' <br /> TYPE C 1.GAS STATOR C 1 FARM 13 E.COMMERCIAL ❑ 1 PARTNERSHIP 1: T. FECERAL AGENCY• 402 <br /> C3 2.DISTRIBUTOR ❑ a.PROCESSOR A B.OTHER a03 <br /> TOTAL.NUMBER OF TANKS Is taOCt/w IMien 0.eeerveuw w 'If owner of UST a puOliE e9ency,nems of 4wmnwpl <br /> REMAININGAT SITE WatlanBa7 MMsi.,lemon er p .wektl tqe .me UST. <br /> �' (Thais ihs <br /> 77-77&7 <br /> 40A ❑Ym Np 4Q5 ma 7x._ a)a i clI Ati <br /> c, <br /> IL PROPERTY OWNER INFORMATION <br /> PRCPPyITY INNER NAME, _ 407 PHONE 408 <br /> - � r ''T�t?of ',—{`,±'y, �(� _ :y,L,^•-S <br /> MAILING OR STREET AOCRESS 409 <br /> ,,� `"•Tr `J '-A � fii <br /> 418 1 5 A 411 ZJPCCOE 412 <br /> Cyt. <br /> PROPERTY OWNER TYPE C 2 INDIVIDUAL Z. LOC>LAGENCYIOISTRIT C S. STATEAGENCY 413 <br /> ❑ 1. CCRPORATICN C ] PARTNERSHIP ❑ S. COUNTYAGENCY C 7. F=EDERALAGENCY <br /> III.TANK OWNER INFORMATION , <br /> TANZ�OWM.N RNAME,ae ,r-, 7 '' ,, 414 y`'`P�HONE 415 <br /> ti. ��) Ci� � 5�'J1L11tf�1'L.'V+ IL1-'�• st•2: :,','j�...y <br /> MAILING OR STREET ADDRESS ��{ �• _ J 416 <br /> -� 1cz a—A.1; Brut e <br /> CRY 417 STA 418 1 ZIPCOO 419 <br /> TANK OWNER TYPE C 2 INDMOUAL 4 LCC.LLAG.ENCY I DISTRICT C fl STATEAGENCY A20 <br /> C 1. CCRPCRATCN Cl 1 PARTNERSHIP C S. CCUNTYAGENCf C 7. FEOERALAGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGEFEE ACCOUNT'NUMBER <br /> TY(IK)HQ 4 4 - Call(916)322-9669 H questions ansa 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY yy�� <br /> iNOIGTE METHOO(S) 1:11. SELF4NSUREO C 4. SURETY BOND C 7. STATE FUND A10. LOCAL GOVT MECHANISM <br /> C 2 GUARANTEE C 5. LETTER OF CREDIT C B STATE FUND&CFO LETTER C 99.OTHER: <br /> C 3. INSURANCE C 6. E%EAPnON C 9. STATEFUNC&CD 422 <br /> VT.LEGAL NOTIFICATION ANO MAILING ADDRESS- <br /> CTe4k Ana Dox m inmsm wNa a5max ermltlC Oe mn0 for IA9al noO5o8one alts mvai <br /> Legal no95ollw8 Lm mWm9a wJl ps A4NKmIM rru arwrmleu hostar2is tllerAe4 . ❑ 1.FAL211Y 2 PROPERTYCWNER C I TANKOWNER 423 <br /> i <br /> VIL APPLICANT SIGNATURE <br /> Canalomn Im1R71Ntmei - 91vem5lulemupun Mamusm mew Ona of my 101RA'Ie09n. <br /> SIGNARTURE AP P GATE A21 INE 425 <br /> J �"'�'�',�r�`j y� <br /> NPM6%CF APR,UI;ANT(Aft) y 425 TITLEp APgPUGVIT m <br /> STATE UST FACILITY NWaBFR(Farfaol ua w47 428 1995 UPGRnCE CEIYTIFlGTE NUMBER(Farleol usv ANY) 429 <br /> UPCF(1/99) Fwm ty SWRCS Foran A <br />