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U EO PROGRAM CONSOLIDATED FO <br /> UN qyyRCND STORAGE TANKS - FACILITY TANKS <br /> OMO aersfei <br /> Pam Of _ <br /> TYPE OF ACTION ❑ <br /> 1-NEW SITE PERMIT C ].RENEWAL PERMIT B.CHANGEOFINFORMATICN S <br /> (Chace oneiRmaNy) y� rpeONmama- Q 7.PERMANENTLY CLOSED SITE <br /> ❑ 4.AMENDED PERMIT lam aae anNl Q S.TANK REMOVED 409 <br /> Q S.TEMPORARY SITE CLOSURE <br /> L FACILITY I SITE INFORMATION _ <br /> BUSINESS NAME(Sam.as FACILITY NAME MORA-Ookp Baamea Asl 3 FACILITY 100 - i <br /> 1Y B ' 'LC.a-� "e ,4t.1\ V4C�' '^' aiAa#\ `4P <br /> NEAREST CROSS STREET 491 FACILITY OWNER TYPE i LCCALAGENCYNISTR[Cr <br /> Q 1. CCRPORATICN QallSIN5, COUNTY AGENCY• <br /> Q 2. INOMOUAL <br /> ttPE EBS Q 1.GAS STATION Q 3.FARM Q S.COMMERCIAL ❑ 1 PARTNERSHIP Q S. STATE AGENCY• <br /> ❑ 2 DISTRIBUTOR ❑4.PROCESSOR ,�) S.OTHER 400 Q 7. FEDERAL AGENCY• 402 <br /> TOTAL NUMBER OF TANKS is favlity an maim Reeerommo or 'If owner 0 UST a Pool.egmr ..name of sapemaeraf <br /> REMAININGATSITE nomanae7 000elom eemon armam wnnn operates me UST. <br /> y (This is ma mnu�IM person/o{Jme WNremms.) i '� <br /> 404 405 <br /> Q Yes l']7 NO 405 li y'..tl.(3. 6� . I y- �4 'S o- f.. L. a`?v <br /> if.PROPERTY OWNER INFORMATION <br /> PROP STY INNER 407 PHONE 409 <br /> MAILING OR STREET ADORE 1 <br /> y 4 410 STATE, 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE Cl L INDIVIDUAL ' LOCAL AGENCY I DISTRICT Cl S. STATE AGENCY 413 <br /> Q 1. CORPORATION ] PARTNERSHIP Q S. COUNTY AGENCY ❑ 7. FECERALAGENCY <br /> III.TANK OWNER INFORMATION + <br /> TANK,,OWNFA NAME L+1 414 PHONE 415 <br /> MAILING OR STREET ADDRESS uS 416 <br /> r^ 1 <br /> 417 STAM418 DP 419 <br /> CA <br /> TANK OWI4ERTYPE Q 2. INDIVIDUAL M`� <br /> Q 1. CORPORATION YLOCALAGEENCY STRICT ❑ S. STATEAGENCY 420 <br /> Q S.7. PARTNERSHIP Q S.COUNTY AGENCY C 7. FEDERALAGENLY <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO 4 4 Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIALRESPONSIBILrrY - <br /> INDICATE METHOD(5) Q 1, sELFNSU use ❑ 4. SURETY BOND Q 7. STATE Rw i~ '0. LOCAL GOVT MECHANISM <br /> Q 2 GUARANTEE Q S. LETTER OFCREOIT Q e. STATE FUND&CFO LETTER ❑ 99. OTHER: <br /> Q 3. INSURANCE Q 8. EXEMPTION Q 9. STATEFUND&CO 47Y <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chedr one baK to intiote wlatll aatlreas a11oNa m ass01ar M9a1 maeiaaona arm mating <br /> Le9alnaa mmamaM muam)s wJl ae eernmme Gnk orwrumau boi l art isdlerhM Q 1. <br /> FACILITY ," 2 PROPERi1'OVIMER Cl ]. TANK OWNER 4A <br /> `AI.APPLICANT SIGNATURE <br /> Cdr Gaam 1®rNy mamm immrfaaon omwaea twevl M am w�O amimm m aw Dear of my kmwlstlgs. <br /> 5IC?1�TUREO AP �P. 1 DATE 424 PHONE 425 <br /> c�'ti' aa•��y--- �V,1;�dL'B�� a�'�';a.r1 1'.2��u '9 ���iii"� �'a''�`� �3 <br /> NAMECF APT0.1 (Prot) yy 429 TRLE CANT 427 <br /> STATE UST FACILITY NUMBER(Farlaolusaaay) 420 less UPGRADE CERDFICATE NLlMSER(Pgrasaf oaFYI 479 <br /> UPCF(7199) Formerly SV4i FOM A <br />