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i nA, - <br /> ` + FIED PROGRAM CONSOLIDATE r�IORM j <br /> N <br /> TANKS <br /> - FACILITYUNDERGROUND STORAGE TANKS <br /> ne iage4s,,e)Page _ mt.'PE OF ACTION r 1.NEW SITE PERMIT RENEWAL PERMIT r 5.C:.4ANGE OF INFORMAT;CN iSoea:j grange- 7.PERMANENTLY OS=0 SI <br /> (C'eee one item only) ocar use only) r a.TANK REMOVED - ff <br /> (� a AMENDED PEFLMIT <br /> r o.-EMPORARY SRE CLCSURE <br /> I I.FACILITY I SITE INFORMATION <br /> S;NESS NAME(Same as FACILITY NAME or OBS.-Dong Business As) 3 FACIUTY'0 a <br /> I <br /> if-IC, M I 0I I°Z-T _ I 11 I I I <br /> P-�PG <br /> NEAREST CROSS BTR ET ITY OWNER TYPE r 4. LOCAL AGENCYr015TRICT• <br /> TION <br /> tnM�,�f � 1( „RPORA I- 5. COUNTY�,GENCY- <br /> BUSINESS TYPE r t. S STATION ` r 3.FARM r i.COMMERCIAL r 2. INGNIOUAL [ 9, STATE AGENCY' <br /> r <br /> I TRIBUTOR r 4.PROCESSOR r o.OTHER r 3. PARTNERSHIP I' T. FEDERAL AGENCY- 402 2.DISTRIBUTOR 1 <br /> 403 <br /> TOTAL NUMBER OF TANKS :s ra=cy on Inctan Reservauon or f owner of UST's a;uoin agencr.name ar sucerv,sar of <br /> REMAINING AT SITE m4saands7 ;rwsnos secwt Of oer5 wrnrn acerates cor UST. <br /> \ (Thts a the cantaa arson for the tarot retorts) <br /> 404 r Yea r No AM <br /> 11.PROPERTY OWNER INFORMATION <br /> PHONE 408 <br /> PROPERTY OWNER NAME 407 <br /> � A CAb(ZE (,It��lvUlt � ZttC, . <br /> MAILING OR STREET ADDRESS 409 <br /> 5 Pae-I �� A .�cv��.t e <br /> I STATE 4:+ I zlPcooE 412 <br /> c;n 4,o f <br /> S+Q�4;- -on CA - GSA <br /> PROPERTY OWNER TYPE [ Z. N0IVIOUAL 4. '-OCALAGE.NCY/DI$TRtCT r i. STA—..AGENCY 4;3 <br /> �/10ORPORATICN 3 PARTNERSHIP [ i. COUNTY AGFNCY C 7 FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION _ <br /> PHONE 'is <br /> TANK OWNER NAME 414 <br /> MA'L!NG OR STREET AOORESS 416 <br /> 317 STATE .8 i 21P 000nE 419 <br /> CA I <br /> 6� I > > ATE AGENCY 120 <br /> -ANK OWNER TYPE [-2.;NONIOUAL r a. LOCAL AGENCY l OLS-,RICT <br /> r <br /> ,. CORPORATION r i. COUNTY AGENCY f FEDERALAGEENCY <br /> ARTNERSHIP -- <br /> EEE A=i iNT%it ImRF::? -- <br /> T'{..TK)HO 1 4 4 I I I I Call(916)322-9669 if questions arise <br /> V PCTRQI e1 veenucrvu tr - <br /> tNOICATE METHOO(S) t. SELF�NSURED r 4. SURETY BOND r 7. STATE FUNO r 0 OCAL Dov T MECHANISM <br /> r <br /> r 2. GUARANTEE r S. LETTER OF CREDIT r B. STATE FUND&CFO LETTER r 99. OTHER sZ <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 3 CO <br /> S2 <br /> C1ecx one box to noicate wrnss cn addresnouid be used for"al ndaficattont and made,g. r ' FACILITY r 1 PROPERTY OWNER r 3. TANK OWNER _ <br /> aI non(catrons and madinas will be sem o me ram owner unless bdx,Of n Gutted <br /> o <br /> Cardlcabon: I candy that the information crov,ded herein is true and accurate to the best of my kndwtedce. i2 <br /> GNATURE OF APPLICANT <br /> 'DATEE 424 I NE <br /> SI <br /> 4251 -CTL-OF APPLICANT 427 <br /> NAME OF APPLICANT(Annr) <br /> ST.TE UST FACILITY NUMBER(For acal use,onrvl 4281 -l8 UPGRAOE CERTIFICATE NUMBER Iia:ocar ase onIy) 429 <br />