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UID PROGRAM CONSOLIDATED <br /> �FE �RM <br /> TANKS :; <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per sire) <br /> Page _ of _ <br /> TYPE OF ACTION [- 1.NEW SITE PERMIT F 3.RENEWAL PERMIT F S.CHANGE OF INFORMHPON rSoeary orange- F %.PERMANENTLY CLOSED SITE <br /> ICheca one Rem ably) <br /> [�4 AMENDED PERMIT oral uu only) TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME of DBA-Damp a...Asa 4 FACILITY 10 s <br /> NEARE <br /> ,jCFffSTREEr4, LOGLAGENCY/DISTRICT• <br /> V ' C 1. CORPORATION <br /> ram MONIDUAL F 5, COUNTY AGENCY' <br /> BUSINESS TYPE <br /> [� t.GAS STATION F .FARM F i.COMMERCIAL "L F 5. STATE AGENCY' <br /> F 2 DISTRIBUTOR F 4.PROCESSOR F 6.OTHER F 3. PARTNERSHIP F 7 FEDERAL AGENCY' 402 <br /> 4N <br /> TOTAL NUMBER OFT ANKSIs <br /> FTANKSIs faaem/on IMIan Resenamaa w 7f owner of UST e a a I c Nenv acme of sc bsaf at <br /> REMAINING AT SITE at umaas? a smn.secam w afire wnxm aoeas.me UST. <br /> (Th...me comae m aersw me mss remrds.) <br /> 4G4 F Yes No 405 406 <br /> Il.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 TATE sn LP CODE a12 <br /> PROPERTY OWNER TYPE 2. '�NOIVIOUAL F 4. LOCAL AGENCY I DISTRICT F 3. STATEAGENCY 413 <br /> [ t. CORPORATION (- 3 PARTNERSHIP F 5, COUNTY 4GENCY F 7 FEDERALAGENCY <br /> Ill. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 41S <br /> MAILING OR STREET ADDRESS 416 <br /> -Cir, 417 STATE 418 ZIPCCOE 419 <br /> TANK OWNER TYPE VIZ 1NONIDUAL F a. LOCALAGENCY/DISTRICT F 5. STATEAGENCY 420 <br /> F 1 CORPORATION [' 3. PARTNERSHIP F 5. COUNTY AGENCY F7 FEOERALAGENCY <br /> TY(TK)HO 4 a 1 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) F 1. SELF-INSURED F 4. SURETY BOND F 7. STATE FUND F 10. -OCAL 301 MECHANISM <br /> F 2 GUARANTEE F 5. LETTER OF CREDIT F 9. STATE FUND&CFO LETTER F 39 OTHER <br /> F 3. INSURANCE F 6. EXEMPTION F 9. STATE FUND d CO 422 I <br /> Che,,one box Io Mbiaate wn cm adarces tritium be items for"se rwtifimdo.and he". 1. AGILITY F 2 PROPERTY OWNER F 3. TANK OWNER a23 <br /> saw at,ficavch.and maiti wo b I. CdeIX <br /> Vit APprIrAk17QI�MAT1IDC it <br /> Owiticatwn' I mnlfy that Me infarmalmn ofMpea been is we aq aWYde m UW I»A of my kMwleags. <br /> SIGNATURE OF APPLICANT DATE 11-24 <br /> 424 PNON 425 <br /> NAME OF APPLICANT(poop 426 T RLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Farocal a ohii) 4281 1958 UPGRADE CERTIFICATE NUMBERIFor.ofal use MYJ 429 <br /> I <br />