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U IEO PROGRAM CONSOLIOATE O RM <br /> V ( � TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY 9 (one pa We) <br /> r 7 PERMANENTLY CLOSED SITE <br /> ,•!PE OF ACTION r 1.NEW SITE PERMIT r 1.RENEWAL PERMIT r 1 CHANGE OF INFORMAi;CN ISm iyat - I. 5 TANK REMOVED 40 <br /> (Chau,one tern an1y) 4 AMENDED PERMIT 'txa,'Am,may) <br /> r 5.—,,MPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Sarrt as FACILITY NAME t'DBA-O0sl9 Bluness A6) 3 <br /> FacluTY ID a <br /> FACILITY OWNER TYPE r 4. LOCAL AGENCYIOISTRtCT' <br /> NEAREST CRO55 b I 401 r 1. CORPORATION r 5. COUNTYAGENCY' <br /> BUSINESS TYPE MMERCIAL <br /> INOMDUAL I r 6. STATE AGENCY• <br /> 2 2 DISTRIBUTOR PROCESSOR r S.O GAS STATION r 7.FARM r S_COr 3. PARTNERSHIP r 7. FEDERALAGENCY' -02 <br /> r r 4. 43ER <br /> 'if 9 t UST s a arDnc agencl name R;uPeA^stlt W <br /> TOTAL NUMBER OF TANKS s faaNY an IMtr Reservatl4n ar wem lemon ar OVre wnlrft 00erates:,e UST. <br /> REMAINING AT SITE Dus ssYdel (au Ne Dontaa Ders9n w the tars,remtsl <br /> 404 3 rYes N0 405 m <br /> It.PROPERTY OWNER INFORMATION I PHONE 406 <br /> PROPERTY OWNER NAME a07 rw rLPM' � <br /> MAILING OR STREET ADDRESS 109 6' <br /> S <br /> CITY AT at1 I ZIPCODE a12 \ <br /> 410 h' <br /> r A. LOCAL AGENCY I DISTRICT r i. STATE AGENCY a13 <br /> PROPERTY OWNER TYPE r L NOIVIOUAL r r 7 FEDERAL AGENCY <br /> t. CORPORATION r l PARTNERSHIP r S. COUNTY AGENCY <br /> III.TANK OWNER INFORMATION <br /> G I PHONE 415 <br /> TANK OWNER NAME sta <br /> ,d r �y <br /> NA, I G OQS'{'RJ=ET ADDRESS 416 4 <br /> !(7y f/{A D r • 3iA18 I LPA. <br /> COO a19 <br /> Clrr, 417 <br /> G r 4. LOCAL AGENCYIOLSTR'CT r i. SiATt.t`tCY 420 <br /> TANK OWNER TYPE INOMDUAL r 7. FEDERAL AGENCY <br /> r t CORPORATION r 3 PARTNERSHIP r S. COUNTY AGENCY <br /> 421 <br /> TY ,TK)HO 4 4 - Ill I Call(916)322-9669 if questions apse <br /> C 7 STATE FUND r 10. LOCAL GOV-TMECHANISM <br /> INDICATE METHOO(S) r 1. SELF-INSURED r 4. SURETYSOND •���rrr <br /> STATE FUND E CFO LETTER r 9. OTHE a22 <br /> r 2 GUARANTEE r S. LETTER OF CREDIT r.4 STATE FUND S CO <br /> r 3. INSURANCE r i. EXEMPTION <br /> C�mnOtR bo Qn a�iM�tawnirh�tlaess znDUM ins owfnert�eestDo irons 11 r t. FACILITY <br /> L PROPERTY OWNER r 3. TANKOWNER 423 <br /> ets <br /> 1 � <br /> Candiratwn' I <br /> ;1,that tM inf0rmaa0n 0rosa1W herein a tru9 ane a ate to the Dest W my s IeOge. 424 PHONE425]ATESIGNATURE OPLICANT426 ,TTLEOFAPPUCANT 127 <br /> NAME OF APPNT(pnn0 <br /> 4218 '.?59UPGRAOECERT.F;UMIjuM6ER( .Fat,se 0e1Y) 424 <br /> STATE UST FACILITY NUMBER(F0•'O useaey) <br /> 0 <br /> to�3�p1 <br />