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Nov 09 05 11 : 05a M I Whitects 92594381 p. 6 <br /> I HI4 WMD PROGRAM((?NSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS-FACUffff <br /> (-page per Dirt) Page of <br /> momAl FERbIIT ❑5.CiU►NGE OF iNFORMAT[tNl O pyER)i{ATIHIVTLY CLOSED SITE 1 <br /> TYPE OF ACTION i.NEW srrF PERWT 0 3.RENEWAL nay (3 8.TAiIK R6MOYED <br /> (Chock sae item aaly) ❑4.AMENDED PlsRh1IT spel choptow ox � r� �� L <br /> ❑&TEMPORARY srm CL031)RE 1 /� <br /> L FACUMV 1 SITE INFORMATION <br /> BUS[NESS T1AME(s mi,dFwcn m HAe�e.oeus- A■3 a FACIL11T ID= <br /> C t s s ' <br /> FLE19 <br /> f aol FACA TiY OWNER TYPE 4.LOCAL AG !DISTRICT' <br /> NEAREST CR STREEC 1.CORPORA1iON ❑S.COUNTY AGENCY* <br /> 81►51NESS L GAS STATION 3.FARM 5. CP2II+sEItCL�I 13 2•ENDIVIDUAL ©6 STATE AGENCY' <br /> 4.PILOCES.4cili❑6.OTHER ❑3.PARTNERSHIP ❑7_FEDERAL AGENCY* 401: <br /> TYPE ❑2.D15TR�LrmR ❑ of tlivisEoa seWiOO oremix w" <br /> TOTAL NUMB17t OF TANKS <br /> is email+on Iedialn Resavnfi-a gfas�steraf cur is s wimu aSil rum ofa <br /> REMAINING ATSITE fits ? s(l3isistictmmsctpersmfar+kcuet*aoads) <br /> aoa <br /> 4-4 [) Yea ❑No 4p° <br /> IL PRUPERTY OWNER UeNXWATM <br /> pRpPFo�n+n>rrN�NAME am PHONE <br /> MAILING OR SSTREFT ADDRES <br /> V : MID $TATE 4i1 21P CODE !Pfl <br /> CITY �C��i��� <br /> PROP,ILTY OWNER TYPE ,.CORPORATION 2.RWTVMUAL 4.LOCAL AGENCY11)W1RICT e t ATE AGENCY ais <br /> ❑3.PARTNERSHIP 0 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> 414 PHONE <br /> TANK OWNER NAME � r <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> 4r STATE als ZIP C�r-U�6. <br /> ns <br /> CITY '� <br /> I_CORPO1tATiON Z INDIVIDUAL 4.LOCAL AGFIVCY/DiSTSTATE AGENCY r.4 <br /> TANK OWNER TYPE <br /> 03.PARTNERl Q 5.COUNTY AGENCY J37 FEDERAL AGENCY- <br /> 1V.BOARD OF EQUALM&TION UST STORAGE FEE ACCOUNT NUMBER <br /> CR(916)322-9669 if arise <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE i+•IEff1OD(a) ❑1.SH].1v1NSURM ❑4.SURE f Y BOND O 7 STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> [17-GUARANTEE [35-LETTEROFl a3 INSURANCE ©6•� [:19.STATE FUND&CD LECCI:R ❑94.OTHER: 4.2-2 <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chtxk Inc box to ioditatc which add,as should be teed far Ityd nolEfiafinm and C3 <br /> VX <br /> Legal notifications and mailili will lie scat 1*tha unk asrnanokss bar t Or 2 isc6edttd- © L FACILITY ' 2 pROP1'AiTY OWNER (33.TANK OWNER <br /> VQ.APPLICANT SIGNATURE <br /> Ca$fitoilan- that the iafaom:nms bateia is uae ad mu It to the bat of ay koo-1od8c•DATE PHONErc <br /> SEGNA FA ,CANTr�� O 1� ' <br /> 42bTITLE()F yam. <br /> NAME OF APPJACANX <br /> p-. <br /> STATE UST FACILITY NUMBER(Forwa►uwc*) -:S I"gUPGRADE 9jtMRCATENUMBER(F.bcd-mady) <br /> UPCT(1199 Icviseci) 9 Facmedy SWRCB Form A <br />