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UNIFIED PROGRAM CONSOLIDATED FORMI, <br /> TANKS ; <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> ii (one Page per site) <br /> Page _ of _ <br /> TYPE OF ACTION [' 1,,YEW SITE PERMIT r 1.RENEWAL PERMIT r i.CHANGE OF INFORMAT;ON(Siteory change- r 7.PERMANENTLY CLOSED SITE <br /> lcllcx one Rem only) [- a.AMENDED PERMIT Loiuse only) r8.TANK REMOVED 400 <br /> a.TEMPORARY SITE CLOSURE <br /> 1-FACILITY I SITE INFORMATION li <br /> FauL <br /> IN�E'SSSSNAMEISameas FACILITYNAMEor O6A-0wq BNsuees Asl 3 FACILITY IDA I I I I I z <br /> W\SFACILITY OWNER TYPE [' <br /> NEAREST CROSS STREET 40t a. LOCAL AGENCYIp15TRICT' <br /> Y/�A� r 1. CORPORATION r 5. COUNTY AGENCY- <br /> aU INES TYPE [' tI GAS STATION r 1.FARM r i.COMMERCIAL 2. INOMOUAL [- J. STATE AGENCY' <br /> r 2 OISTRIBUTOR r a.PROCESSOR r 5 OTHER r 3. PARTNERSHIP [ 7 FEDERAL AGENCY- 4@ <br /> 403 <br /> TOTAL NUMBER OF TANKS Is hour/on Imen Reservatm or '1f owner a UST s a o,xrw agency name of awervnor of <br /> ftOTAININGAROFT SITE is Cacansoanos? ON...secoan or rn8ra wnlm ocareaee ne UST. <br /> \,-. (Thin is the cancan oarson for the carat remrttel <br /> 404 ['Ye, la Na 405 4)6 <br /> 11-PROPERTY OWNER INFORMATION <br /> PHONE 408 <br /> PROPERTY OWNER NAME 407 <br /> MAILING OR STREET ADORES$ 4pg I <br /> STATC 411 ZIP CODE 412 III <br /> FPROPER� <br /> 10 i I ci' 33 <br /> WNER TYPE 2 INOIVIOUAL r a. LOGY AGcYCYIOISTRICT C 5. STATE AGENCY 413 <br /> r CORPORATION 3 PARTNERSHIP r 5. COUNTY 4GENCY r 7 FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> *TANKO�ERNAME14 <br /> H -RESS 4:5STATE 418 Ier►.f+�c� I � � `1533�, I <br /> TANK OWNER TYPE 2. INDIVIDUAL r 4. LOCTL.AGENCYl0157RICT rj. STATEAG NCY 20 <br /> r I CORPORATION ( 3 PARTNERSHIP r COUNT GENCY r 7 FEDERALAGENCY <br /> IV an <br /> TY�TK)HO Call(91 fi1 322-9669 if questions arise 421 <br /> 4 1 4 - 1 I <br /> INDICATE METHOO(Sl [- I. SELF-INSURED r ; SURETY BOND r 7. STATE FUND r 10. LOCAL GOVeT MECHANISM <br /> r 2. GUARANTEE r i. LETTER OF CREDIT r 9. STATE FUND 8CFO 1.Ei TER r 99. OTHER: <br /> F 3. INSURANCE r 5. EXEMPTION r 9. STATE FOND S CO <br /> 7i;ADD <br /> Che,t,one wx to indir(th ooresa snouln oa lase for 100 na"ka"ahs aro mating. r ' FACILITY ? PROPERTY OWNER r1. TANKOWNER 423 <br /> f M II1e t Aral ie wx1o,11SMa an <br /> CanRCatwn: I cemfy that V19 RAarman n Of0`/gae heron Is wa aM amxate Io the ben Or mY Nor e'"O. <br /> SIGNATURE OF APPLICANT GATE 424 PHONE 425 <br /> NAME OF APPLICANT(pnnrl 4261 TITLE OF APPEEW 427 1 <br /> STAiE'JST FACILITY NUMBER fFonow use Dory/ 4281 '998 UPGRADE CER7.FICATE NUMBER IFor mcal use only) 429 <br /> I <br />