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IFIED PROGRAM CONSOLIDATE:ORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per <br /> Page _ of <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT CHANGE OF INFORMATION(Speciry charge- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4.AMENDED PERMIT local use on IF 40 <br /> &TANK REMOVED 0•�_ <br /> r 6.TEMPORARY SITE CLOSURE � <br /> Q I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY 10 a <br /> o�q' LdA 114e <br /> NEAREST <br /> -CR�SSTREE 401 1 15, Vr FACILITY CORPORATION r 4. LOCALAGESTRICT• <br /> BUSINESSES TYPE r 1.GAS STATION 3.FARM )K5 COMMERCIAL COMMERCIAL r 2. INDIVIDUAL r 5.g COUNTYAGENCY' <br /> /sem' r 6. STATE AGENCY• <br /> r 2.DISTRIBUTOR r 4.PROCESSOR IF 6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is Imlay on waiter,Reservation or 'If owner of UST is a public agency:name of suoervisor of <br /> REMAINING AT SITE Hatteras? diveki section or office whim operates the UST. <br /> (This is lite contact person for Ne lank records.) <br /> 404 r Yes o 405 a06 <br /> II.PROPERTY OWNER INFORMATION _ -,737,o <br /> PROPERTY OWNER NAME 407 PttHOrfNE 408 <br /> MAILING OR STR ET ADDRESS 4 <br /> 1101,16 <br /> 1 <br /> CITY 9 0STATJj, `6all ZIP COD12 <br /> E ') q <br /> PROPERTY OOMER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATEAGENCY 413 <br /> r 1. CORPORATION PARTNERSHIP r 5. COUNTYAGENCY r 7 FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION R'i PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HQ 4 4 - Y� Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT r S. STATE FUND&CFO LETTER >1�9. OTHER: N QTLkf <br /> r 3. INSURANCE r S. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications as mailing. r 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sant to me tank owner unless box 1 or 2 is checked. <br /> Certification: I cenify that the information prm,ded herein is true and accurate to the best of my knowiedga. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(pant) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use of 429 <br /> 731-Do <br />