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IFIED PROGRAM CONSOLIDATE,60RM <br /> TANKS ! <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION r 1,NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION f5pecify charge- r 7.PERMANENTLY CLOSED SITE <br /> fCheck one item only) r 4.AMENDED PERMIT localuseorily) r8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> ,y, a I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Sam�eas , IL TY NAM or DBA- omg Business 1 3 FACILITY 10 p <br /> NEAREST CROSS <br /> STREET d01 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT" <br /> r 1. CORPORATION r 5. COUNTYAGENCY' <br /> allSINESS TYPE [' 1.GAS STATION r 3.FARM r S.COMMERCIAL 2. INDNIOUAL r S. STATEAGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is faality on Inman Reservation or "If owner of UST <br /> a mol-agenq:name of aupervisor of <br /> REMAINING AT SITE nusaarw57 dimsion,seCron or pfr¢e wnirh operates the UST. <br /> ( (This is the mnt=person for the lank resom l <br /> 406 <br /> 404 7�� r Yes r No 405 <br /> II. PROPERTY OWNER INFORMATION <br /> PHONE 406 <br /> PROPE�R/TjY�OWNER NPME 4007 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 _ ^ w STATE btt ZIP 00 412_ <br /> OCR <br /> G aC, <br /> PROPERTY OWNER TYPE INDIVIDUAL C 6. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3 PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> TANK OWNER NAME 414 <br /> S a-,I.) <br /> MAILING OR STREET ADDRESS 416 <br /> STATE 418 ZIP CODE 419 <br /> CITY 417 '��rrr---//l <br /> TANK OWNER TYPE g2. INDNIDUAL r 4. LOCAL AGENCY I DISTRICT r S. STATEAGENCY 420 <br /> r 1. CORPORATION r 3 PARTNERSHIP r 5. COUNTYAGENCY r 7. FEOERALAGENCY <br /> TY(TK) HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) [' 1. SELF-INSUREO r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r e. STATE FUND a CFO LETTER r 99. OTHER:_422 <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD <br /> ^ °F`C�C[ - <br /> Ch ck bo I no,cat. tich address snald ba used for legal notRtcations and mailing. r 1. FACILITY /�. PROPERTY OWNER 1 3. TANKOWNER 423 <br /> Lectal notifisiatichsd nissimIb tt h tank ties until I r2,S,,haossQ <br /> CentfiWtion: I candy that Ne mformation pirvlds l herein is true and accurate to Ne best of my knov4edge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fprlocal use Dory) 426 1998 UPGRADE CERTIFICATE NUMBER(Fbrlocal use only) 429 <br /> F�DDla3 `f'8 7- <br />