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. UNSIEO PROGRAM CONSOLIDATED F. M <br /> NS <br /> TANKS , <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> j tone page per site) <br /> Pat. _ of _ <br /> TYPE OF ACTION r t.NEW SITE PERMIT r 3.RENEWAL PERMIT r S.CHANGEOF INFORMA'CN tSpeary mange- r 7.PERMANENTLY CLOSED SITE <br /> (CSeoe ona item oMy) <br /> OGt�ODO R95� r 4 AMENDED PERMIT r a '.MPCRA Y r 8.TANK REMOVED <br /> . ,,cMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME N ORA-DOM B,,PatU AS) 3 ` FACILITY 20 a <br /> Es-rr7rE- .4 fir Rli- O F'af, o 1 5 e <br /> NEAREST CROSS STREET 401� FACILITY OWNER tYPE r a. LOCAL AGENCY/DISTRICT• <br /> LG. Y l I. ZORPORATION r S. COUNTYAGENCY' <br /> 3USIN 5 PE r 1.GAS STATION 7q.FARM r S.COMMERCIAL '— INONIOUAL <br /> r S. STATE AGENCY- <br /> r L DISTRIBUTOR r 4.PROCESSOR r S.OTHER r 3. PARTNERSHIP I r 7. FEDERAL AGENCY- 402 <br /> no3 <br /> TOTAL NUMBER OF TANKS Is raaury on Inam Reserra wast or 'If owner of UST s a puotic agarlq:name R a+pen�sN of <br /> REMAINING AT SITE wsurlas? oN,smn sxTlon N office wnKn Posts,"Tb UST <br /> 0 406 <br /> (This,s u1e canroa Deman b me tams rxaa.l <br /> a04 r Yea r No 405 <br /> If.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> (Zq) Y51 -¢359 <br /> MAILING OR STREET ADDRESS 409 <br /> I <br /> ITY tUV SZ r / 1 <br /> PROPERTY OWNER TYPE XL ;NOIVIOUAL r n. LOCALAGE.NCYIOISTRICT r 3. STATE AGENCY 413 <br /> r t. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r7 FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> R le' <br /> "ll <br /> MAILING OR STREET AODRESS 41 <br /> ITr 417 STATE 418 I LIP CODE 419 <br /> TANK OWNER TYPEL INOMDUAL r 4. LOCAL AGENCY t DISTRICT r S. STATEAGENCY 420 <br /> r 1 CORPORATION [ 3. PARTNERSHIP r 5. COUNTY AGENCY r 7 FcDERALAGENCY <br /> IV RqAQn0F:;:QIIAII7A-nn -- qTnpArFpF <br /> TY iTK) HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOO(S) r t. SELF4NSUREO r 4. SURETY BOND r T STATE FUND r to. LOCAL GOV=T MECHANISM <br /> r L GUARANTEE r S. LETTER OF CREDIT r 3. STATE FUND&CFO LETTER �. OTHER: -N <br /> F 3. INSURANCE �3. EXEMIPION r 9. STATE FUND d CO A2-44'1f- J—'0, 422 <br /> Clleoe one oae to imitate wnitll aaames snoop se,uses for I"ad nalmmupns aha madins r 1. FACILITY PROPERTY OVMER r 3. TANK OWNER 423 <br /> Lwai mtsti,utimns and <br /> missnag m.11Ca me tavi, Iea o0 1 12 11 weaea <br /> CarlRrcaaan: I cents ilial its in(Nmelim elmnae0 limen,s INe aM aooaae to tna oast pt my knawba96. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(pnnn 4281 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fa,otoa,use anry) 4281 '998 UPGRADE CERTIFICATE NUMBER IFN iota ose osY) 429 <br /> 33 <br /> aAoL 1 Atm-*wet <br /> aJy�w l aw�,a2� YD <br />