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.�- <br /> a IFI ED P <br /> ROGRAM_1ONSOLIDATED <br /> 1/7ie, <br /> UNDERGROUND STORAGE TANKS - FACILITYAAAAAAAAA. ^AAA ^�_TANKS <br /> TYPEOFACTION - U o <br /> (Coact one item only) 1.NEW SITE PERMIT OM Oege lx ,te) <br /> ❑O.RENEWAL PERMIT )T5.CHANGEOFINFORMATION(SPed7yary <br /> Page _ at _ <br /> ❑ d.AME ED PERMIT local use only) fie' 7.PERMANENTLY CLOSED SITE <br /> ❑ 6.TEMPpgq,Ry gTE CLOSUR-� ❑8.TANK REMOVED <br /> gg <br /> BUSINESS NAME(Same as FACILITY NAM YTIU I.FACILITY/SITE INFORMATION <br /> � ( DaalgaueinemAtl J 5 FACILITY ID• <br /> tiNNi �am F 010,40 - llai, :, <br /> NEARE TCFIOSSS REOT ` 1 <br /> Sdv` t5 3.1.4 j401 FACIUT OWNER PE <br /> BUSINESS ee 0 1. CORPORATION m.LOCAL AGENCY/OISTR,,,. <br /> TYPE 0 t.GAS STATION 0 6.FARM 0 2. INDIVIDUAL ❑5. COUNTY AGENCY• <br /> 2.DISTRIBUTOR ❑ 5.COMMERCIAL 0 0 PARTNERSHIP <br /> TOTAL NUMBER OF TANKS 4.PROCESSOR 6.OTHER 403 06 STATE AGENCY- <br /> REMAINING AT SITE la hairy on laden Reaerwaan or •Il ownx of 07 FEDERAL AGENCY• <br /> Wedanmt UST.oualic agenry,name d eupvtiay of 402 <br /> tlivivOn,eec0an Or oMa•Tio oPornm me UST. <br /> dOd ❑ ,.,/ (Tike is Ns aangq Yea I!S No 405 POrep^W me Ant lemrdy) <br /> P OPERTY OWNR NAME II.PROPERTY OWNER INFORMATION <br /> It eVeko vh <br /> MAIUNG OR STREETKESS 407 PHONE <br /> G �6 <br /> 02 2a v` �`t•93� <br /> CITY l GG <br /> 09 <br /> O N ng STATE 411 <br /> PROPERTY OWNER TYPE LPC OE Ott <br /> 0 t. CORPORAnCN 0 2. INDIVIDUALgSzoZ <br /> 3. PARTNERSHIPe. LOCA AGENCY/DISTRICT <br /> ❑ 5. COUNTY AGENCY 0 6. STATEAGENOY 413 <br /> ). FEDERAL AGENCY <br /> TANK OWNER NAME p III-TANK OWNER INFORMATION -- <br /> IMAILING OR STREET ADDRESS OU4=t 414 PHONE 415 <br /> CFFY <br /> nfi <br /> 417 STATE 418 ZIP CODE <br /> TANK OWNER TYPE 419 <br /> ❑ 1. CORPORATION 0 2. INOMDUAL <br /> 0 1 PARTNERSHIP d LOCAL AGENCY/DISTRICT <br /> 0 5. COUN YAGENCY 6. STAEEA4�0 <br /> 7 .^-DERAL LAGEN AGENCY <br /> N.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO 4 4 I I I Call(9 16)322-9669 if questions arise <br /> 421SIBILITY <br /> INDICATE METHOO(5) ❑ V. PETROLEUM UST FINANCIAL RESPON <br /> 1 SELF-INSURED ❑ 4. SURETY SONO �y( <br /> 0 2 GUARANTEE ❑ 5. IETTEROFCREDIT ❑ 7. $TATE FlINp /iL 10. LOCAL GOVT MECHANISM <br /> 0 J. INSURANCE 0 6. EXEMPTION ❑ S. STATE FUND 6 CFO LETTER ❑99. OTHER' <br /> 0 9. STATE iUNOdm <br /> 0. VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> 422 <br /> LpY mrIA inellitlt atldem 4rwtetl ae uaetl forugy lMOfigldana ang mating, <br /> CheckdOak to dole oaon..M <br /> milWga a�11 N Awn Itl me rink ower <br /> miei+eax 1 2,i dlxJled ❑ 1. FACILITY 2 PRGPERTy <br /> ONNER ❑ 1. TANK OWNER 421. <br /> - VII.APPLICANT SIGNATURE <br /> TURF <br /> Gltfl I C"mil me iNgmiE Ganaea Ilecmn u dUe M a0aeepe m ttb Oeil al m kmwytlge <br /> URE OF <br /> �� �klh.eR �YN. DATE 424 PHONE <br /> b Zo 0 1 425 <br /> M 438 TITLE GNT �-� Z- IS3S- <br /> t <br /> ��llrrll h 427 <br /> STATE UST FACILITY NUMBER(Far/eol ass my) - <br /> 4ZB 1998 U5:7PGRADE CERTIFICATE NUMBER(For/ool um orcyJ <br /> 429 <br /> UPCF(1/99) <br /> 9�al JoI ��K/ FOM"SWRCBFormA <br />