Laserfiche WebLink
II4�1FtED PROGRAM CON^ LIDATED FORM TANKS <br /> UNDERGROUND STORAGET S - FACILM <br /> TYPE OF ACTION ❑ 1.NEW s1TE P55ZrP ❑3.RENEWAL PERMIT ,dMNGR OF INFORMATIDN 7.PBRMANt3NTL Y CLOSED SIM <br /> (ch.k am b m only) ❑4.A,MMOED PERMIT tt m*d=p local ome.jy_ ®R TANK.REMOVED <br /> CI&TEMPORARY VM � <br /> I. FACILITY I SITE INFORMATION <br /> BUBMWNAME(Sm aFA=ryXAWact*^bainiaueiaae►s) 3 XlrAC.IISTYW# t <br /> r! 1 <br /> NEAREST CROSS STREET ° 401 FA71)NDIVIDUAL <br /> Y OWNER TYPE <br /> 4.I OCN.AGR3NCY ISTRiCTs <br /> t f' ❑ CORPORATION ❑5.COUNTY AGENCY" <br /> Bug 1.GAS STATION 3.FARM 5, COMUMCIAL 0 6.STATE AGENCY* <br /> TYPE [3 B.DISTRIBUTOR ❑4.PROCESSOR©6. OTk fER 4w Ef 3.PARTNERSH0 Q 7.FEDERAL AGENCY' 4aa <br /> TOTAL NIBVDM OF TANKS I R9 fatality on indian Rmcrvatkm of kWowasr a(UST is a P a,w",mm*of of dlvMdoe,mx0q%walwwhich <br /> RMLkINI O AT 1S� auUb nds4 tie UST(m in dm wnw pence Av the tele ) <br /> ! I x e moo Cl Yea No 403 N 405 <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME rHONE <br /> MAWNG OR STREET ADDRESS 40P <br /> CITY 410STATE 4it ett <br /> G <br /> PROPERTY OWNER TYPE Ll 1.CORPORATION ' INDIVIDUAL 4.LOCAL.AQENCY/DISTRICT 06,3TATEAGENCY <br /> ❑ ,PA,R"TNERS P 0 5,COUNTY AGENCY C37.FEDERAL AGENCY 41) <br /> III.TANK OWNER INFORMATION <br /> TANKNAME 4t4 PHONEa 415 <br /> MAMING OR STREET ADDRESS 410 <br /> l?oyAL- AIVE D&'Vc <br /> CITY 417 STA 41821P CODE 419 <br /> -1r S: a <br /> TANK OWNER TYP 1.CORPORATION 2.(NDUVIDVAL El 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 4= <br /> 3.PARTNS YS9P ®5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FELE ACCOUNT NUMBER <br /> T'Y H 44- Call 936 322-9669 if uestiaas arise 4:1 <br /> V.PETROLEUM UST FINANCIAL RESPONSEBILM <br /> RNDRCATE METMD(s) ❑L SELF-INSURED 0 4.SURETY BOND ❑7.STATE FUND ®10.LOCAL GOVT AdECHANM <br /> ❑2.GUARANTEE ©5.LETTER OF CREDTf .STATE FUND&CFO LETTER Il 99.OTHER <br /> Cj 3.INSURANCE !3 6,MbWTXON 9.STATE &CD 422 <br /> VI.LEGAL NOTIFICATION AND G ADDRESS <br /> Ckaaok one bw w ode www" shoW4 lm eta W 199M PaftftOm 04 mmlb . <br /> L.agil nodfimMum eat muLTep we'll he imt to toe omk aww tmlemm bim 1 at 2 is akemked t.FAcLnT ❑2. PROPERTY owN= ®3.TANK OWN'IBt Oat <br /> VII.APPLICANT SIGNATURE <br /> 1, s eve sod accurate to we bm of my lmowladp. <br /> C DATE <br /> f� 1 l <br /> (print 4m TR F PLICANT <br /> 17 4 <br /> MTTE FACILITY NUMB (Por ioamt vm miy) m i 8 CER CAn NUMBER OW i mtmt um mdy) 4V <br /> UPCF(1/99 s sed) 8 Foraleady SWR03 Form A <br />