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12/29/2006 16: 06 20946P. 433 EHD PAGE 03 <br /> NIFIED PROGRAM C NSOLTDATED FORM <br /> /Lllprp� FAC N; <br /> UNDERGROUND STORALGE TANKS - FACIL Y l 12') -7 Ouj <br /> (one po per site) ) <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ ),RENEWALPERMIT i CHANCE Or MFORMA3ION .PERMANENTLY CLOSED WE <br /> (Chuck oDa ilem oW3) ❑4.AMENOEDPEM1MIT ❑ '� m ❑ R,TANK REMOVED <br /> ❑ EMPORARY SITECLOSURE <br /> 1.FACILITY l SITE INFORMATION 2—L f I)'7 0 5-r, / S <br /> BUSINESS NANIE(sw .,FACIUTY NANEar DEA•DMdawimer N) ) 1PALIL11 ]DF. PRIDx <br /> 11 1 <br /> t. T CROSS STREET � J01 FACILITY OWNER TYPE ❑4,LOCAL AGENCY/DISFRICT• <br /> ❑ IJARPORATION <br /> ❑S.COUNTY AGENCY. <br /> 0 SINESS 1,MDIVIDUAL 4,STATE AGENCY' <br /> TYPE •GAS STATION ❑3,FARM ❑ S.CDNMRCLLL ❑ <br /> ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑4 OTHER 40I ❑3.PARTNERSHIP p T.FEDERAL AGENCY' 407 <br /> TOTAL NUMDE(OF TANKS Is Ta01lit3 on Iw,m HASmarion or -IF..,of UST if a Public galc,:nanc of wpmispr Yf dlagion,xenon a,.[Nr which epandu <br /> REMAMMG AT SITElrustloMs?., ,// the UST(Thla it the eernaat Peraaa fa lite Lvlk ram(b) <br /> E <br /> Oda [] Yes Mo 401 WL <br /> 11.PROPERTY OWNER INFORMATION <br /> Pr7YOWNEAPOE 491 <br /> A <br /> O C <br /> MAILING ORTREE?wDDRESS ^^^ <br /> ZL4QgPrIFS fir: <br /> 410 <br /> ATE 4„ z>P o <br /> crrY n2 <br /> PROPERTY OWNER TYPE ❑ I CORPORATION n T,INDIVIDUAL O 4,LOCAL AGENCY I DISTRICT [16.STATE AGENCY <br /> 03.PARTNERSHIP O 3.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> 111.TANK OWNS INFORMATION <br /> 7AMOOWNERNAM¢ 4m YHO.NEIts <br /> M9AIU�N�G OR S T ADD 5 r e I6 <br /> C m SATE4" na <br /> 2 <br /> T OWNTiR7YP¢ <br /> I.CORPORATION .INDIVIDUAL ❑4.LOCAL A43L'NOY I DISTRICT ❑6,STATE AGENCY AID <br /> ❑ 3.PARTNERSHIP ❑ 5,COUNTY AGENCY ❑7.FEDERAL ACFNCY ' <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> 4 'rY(TK)HQ 44• CEU(916)322.9669 if questions arise 421 <br /> V.PETROLEUM UST FINA NNC,IIAAL RESPONSIBILITY <br /> INDICATE).%7HOD(3) E I.sELF•INSURIED 04.SURETY BOND L7'7.ETATIS FUND ❑ 10.LOCAL COPT MECHANISM <br /> ❑2.GUARAN IM ❑3.LETTER OF CREDrr ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER <br /> ❑1.INSURANCE ❑6.EJ EWTION ❑ 9.STATE FUND k CD 4n <br /> VI. LEGAL NOTIFICATIOAND MAILING ADDRESS <br /> Ord oro boa to Mmmwh,,k.ddwmhoWd be wed for IttAl Rob4emrom and mdin8. I.FACILITY 02.PROPERTYOWNER ❑1TANKOWNER433 <br /> Loo notirmuoD1 snd MA11419 will br I4m w Ihr Bek o'ancr unl4^3 ban 1 or z IldwekNd <br /> VII.A PLICAN SIG ATURE <br /> Cer4A. "r;re tial the in(oml PrgAd.dherein is mle wW sce.alt u dw beH of my lmc-edge, <br /> SIGN OF DATE— 4N PHONE ns <br /> N OF APPLICAN (pant) 426 'ITILG ^3> <br /> STATE USTF CILrrYNIJMBER(Par1w,l4 ^ah) 421 1996 UPGRADE CERTIFICATE NUb1BPR(F011rul err oil>) 4^'s <br /> Is 1998 C^mpliam'1 <br /> UPCP(1199 revised) <br />