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4 <br /> 08/07/2009 09: 05 12093341873 FLAGCITV CHEVRON PAGE 02/03 <br /> UNIV IED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> E: <br /> OPERATING PERMIT A__,PPLICATION—FACILITY INFORMATION(Onotbnn par£ecili,Y) <br /> dM. <br /> 'l'YPF Ur•ACTION C7 I.NEW PERM11' 5.CHANGE Cris INFORMATION El 7.PfiRMANL'N'I'I'AGILiTY CLOSURE <br /> (Cl:vck me Itemonlf) ❑ 3.RCNGWAL IIMMrI' ❑ 6.TEMPORARY FACILITY CLOSURE L) 9A'RANS1`ISR ITItMIT <br /> I. FACILITY INFORMATION <br /> I'OTAI.NUM[IER or US'rs NI'FACIL1'rY n n' FACILITY ID N <br /> H (Agency Use 011W <br /> 19LI91NESSNAME(S�vAACII_ M <br /> "YNAMEarI -DdlNglltai ;Aq <br /> _ T: iaet o l1I, ��et/I'Oi1 an. <br /> HU$IN1, S SI'Pli A'VDR2S5 C.CITYch <br /> G AI <br /> FACIIX1'Y TYPE okI,MOTOR VGmICLE FUL•'LING DIS'llou'rION Is lltc Ihc(lily Iocotcd nu ladipn ItcncrvpLon oK <br /> Trust lnnds? ❑Yes ❑No <br /> 3.FARM JZ 4.PROCC'SSOR 6.OTYER <br /> IL pRoPERTX OWNER INFORMATION <br /> — - - ^a7. PHONr A0� <br /> "'PitOPL•RTY OWNER NAMI: <br /> MAILING ADDRCSS __ <br /> nil. TIP Co1)1 <br /> CITY '1'ATL: <br /> J o S <br /> at�' C�'-� A 7 Z•t-1 2. <br /> T (II. TANK OPERATOR INFORMATION <br /> nxs.l, PRION[_ n1gs <br /> TANK OPCltAT01t NAME <br /> (ley) ,3y _ og7s <br /> KQI.mPL <br /> MAILING ADDI SS <br /> Is <br /> --- 4 <br /> J-0011, <br /> IV, 'TANK OWNER INFORMATION <br /> low <br /> 'TANK OWNER NAME <br /> (2 n�) 33y t87 <br /> vIA, <br /> MAILING ADDRESS <br /> • �___Lod t <br /> nil. 5raT. a41M : •�,^ i <br /> CITY Cz1r cone` <br /> OWNER TYPE! ❑ 4.LOCAI.A0ENCY/I)15'I'mc,r ❑ S.COUNTY AGENCY ❑ 6.mwrii,AorNCY <br /> nen. <br /> ❑ 7.1-rI)EKAL AGENCY R.NON•UOVEtNMCTrr <br /> V. BOARD OF cQUTTIZA,TION UST STORAGE YEE ACCOUNT NUMBER <br /> �• ��I�Q 44, I Yr Cakl the sinto Doted elf Eg1l- iaatlon,NO Tos Divigial, f lhe�c aye 0-110M,m� <br /> ul, <br /> VL PERMIT HOLDER.INFORMATION <br /> lssuo porluit and send logyl nolificntioap and mnilinnc to: C7 I.IyACILITY OWNIIIi <br /> 4.TANK OPERATOR A2] <br /> n 3,'rANK OWNER ❑ 5.I'ACIL.ITY OPIlRAT0R <br /> nn6. <br /> SUPGRVISOROF DIVISION,SKTION,Olt OFFICE(Required For Public AgenciesonlY) <br /> VII.APPLICANT SIGNATURE <br /> CKR'rIPICATIOIN: I cart!fy tlts► he nformnti <br /> t o_n rov( ed 4erein is true acefirfliel and in t'idl compliance with lepi re airomenm <br /> APPLICANT SIGNA'T'URE DAT n PRONE <br /> a ✓ l a o <br /> APPLICANT NAMI:(print) ` nPo. AP('LICANT'll'I'LE ver <br /> K(�1Y►�b�r' S .�y.D � �6� �1� rr'a040lr <br /> UPC( UST"A Rev.(12!2007) <br />