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NOV/20/2008/THU 04:35 PM COS u AEDEV FAX No, 2099375nq9 P. 002 <br /> 11/20/2008 THU 14: 21 FAX 2094es3433 STC EHD 4 <br /> 1 ®002/006 <br /> a /2� n� ��tze�� <br /> u' <br /> UNIFIED PROGRAMCONSOLIDA FORM rJ Z (0 <br /> .. UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFO <br /> ' (One forth Per fecilily) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT Q S.CHANGE OF INFORMATION Q 7.PERMANENT PACILITYCLOSURE nw" <br /> (Check sic lmm only) © 3.RENEWAL PERMIT W6.TEMPORARY FACILITY CLOSURE Q 9.TRANSFERPERMIT <br /> qV_�s L 'FACILITYINFORMATION <br /> / t TOTAL NUMBER OF USTS AT FACILITY aa' FACILITY IDM _ <br /> VV- (dyntry Use Only) <br /> SBUSINESSAME(son-uP CLLRY WN NDBA-ood Ral <br /> IT D S CITY 103' <br /> r\ a <br /> 401. s. <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL.DISTRIBUTION Is thelaws? heated on Indian anon or <br /> 3.FARM Q 4.PROCESSOR 6.OTHER nut VMsYra <br /> IL PROPERTY OWNER INFORMATION <br /> NOI)ERTY OWNER NAME PHONE A <br /> NG ADDRESS <br /> atz <br /> C[ ata STATE 31. ZIP CODE <br /> III. TANK OPERATOR INFORMATION . <br /> TANK OPERATOR NAME °xe.. PHONE nit <br /> grcJ <br /> MAILING ADDRESS <br /> 4zei <br /> CITY STATE 03 ZIP CODS <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 41°. 1 PHONE aU. <br /> ate. <br /> MAILINGADDRESS <br /> CITY <br /> ate STATE 41a ZIP CODE aIA <br /> �- 6.STATE AGENCY am <br /> OWNER TYPE: 4,LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ <br /> Q 7.FEDERAL AGENCY Q S.NON-GOVERNMENT , <br /> V. BOARD OF, EQIJALILAnON UST STORACE.FEE° ACCOUNT NUMBER <br /> irthcre ere goestiona. all. <br /> .(.1(TK)HQ�. Call the Sled Sward of Egwli�mli0n,Fuel Tu Division, .. .•. _ , <br /> VI.PERMIT HOLDER INFORMATION <br /> hsoe Penoit and send legal notifications andmailirtga to: ❑ I.FACILlTYOWNER [I 4.TANK OP®t Mltt, <br /> azs <br /> 3.TANK OWNER d 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE(Requood For Pontic Ageltoies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cerafy1hat the ( mefion provided herein is true scOur4te.,and In fall compliance with legal re ir¢meall. <br /> APPLICANT SIGNATURE OAT ar, PHONE 4xe. <br /> 0 <br /> 43C DPP CANTT LE 4n <br /> LICANT A E(Print) <br /> UPCF US'f•A Rev.(12/2001) <br />