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UISED PROGRAM �M <br /> CONSOLIDATED FOM <br /> �o�,Sl 3 50 <br /> UNDERGROUND STORRATANKS - FACILI <br /> AGE \L� TANKs <br /> TANKS <br /> �L (one ge per site) <br /> TYPE OF ACTION r 1.NEW SITE PERMIT Page _ or � <br /> (Check one item only) r 3.RENEWAL PERMIT r S.CHANGE OF INFORMATION(Speciy change- I1,0��(/]' PERMANENTLY CLOSED SIVE <br /> r d.AMENDED PERMIT kcal use only) 1 g.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Doig Business As) 3 FACILRY IDD <br /> Nan , a5gaa So l <br /> NEAREST CROSS TREET 401 FA IUTY OWNER TYPE r 4. LOCAL AGENCY/OISTRICT' <br /> r I. CORPORATION <br /> BUSINESS TYPE r I.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL r S. COUNTY AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 6. STATE AGENCY- <br /> 403 r 7. FEDERALAGENCY- 402 <br /> TOTAL NUMBER OF TANKS Is faciliry on IIMan Resrnalbn w -I/owner d UST u a ouolk agency,= <br /> REMAINING AT SITE trusganga7 Emskn st�' -,,. <br /> 404 m <br /> r Yes r No 405 <br /> It.PROPER' �Lnr./i <br /> PROPERTY OWNER NAME 407 A�o>�, D PHONE 406 <br /> MAILING ODR S 409 <br /> city 410 L <br /> /`„ UUUt au <br /> PROPERTY OWNER TYPE INDIVIDUAL <br /> r 2. (� Q <br /> r 1. CORPORATION AGENCY <br /> r 3. PARTNERSHIP L I . /] r FEDERALAGENCY <br /> III.TANK C <br /> TANK OWNER NAME 414 <br /> ONE . 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY d1] <br /> ._ pP ODE at9 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 1 - I I I CaII(916)322-9669 if questions arise 421 <br /> INDICATE METMOD(S) r I. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND - r 10. LOCAL GOV-T MECHANISM <br /> r 2. GUARANTEE r 5. LETTFROFCREOIT r 8. STATE FUND E CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Ul 1 FOAI MmTIC1r ATtnm Apin <br /> qA <br /> Check one Wx 1 nM¢ate hrll aaarau shouts be ossa for Iegel naMxxtxxa a cl madmg. r 7•FACILfiY ^ ^r 2. PROPERTY OWNER r 3 TANK OWNER 423 <br /> Legal noti&ations ano mailings will 0e sent to Me tank 311 1 w 2' rhxketl <br /> Certification: I cert4y Ihat Ne eltormatbn provMeg herein is Vlw wlB aawate la 1111 gest o/my ivlowletlge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(prin) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For bcal use only) a2B 1998 UPGRADE CERTIFICATE NUMBER(Fgr kcal use oNy) 429 <br />