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IFIED PROGRAM CON SOLIDAT . ORM i <br /> til <br /> fl <br /> TANKS <br /> GE TANKS - FACILITY <br /> UNDERGROUND STORAGE J <br /> Ile^age per sr;e) <br /> Page _ ::t _ <br /> ,`!PE OF ACTION j' t.NE,N Sf i c PERMIT ]RENEWAL PERMIT r i C.!ANGE OF INFORMA-,,ON iSoec y c7ange- I- i.PERMANENTLY CLOSED SITE <br /> (C:ecx one item only) 4 AMENDED PERMIT ocw use oni 1 r a.rANK REMOVEO 4M <br /> (' <br /> _ r o.—_-'.t?ORARY SITE CLQSURE <br /> I I.FACILITY!SITE INFORMATION <br /> L__ FAC L T O a I I --- <br /> UStNESS NAME(Same as FACILITY NAMEyo-r OB(-Ccwg Buswess As) 3 { I I I I i <br /> � '�t" Mioi ���I I - • tTY'JWNE.RTYPE <br /> VEnREST CROSqS 57RRl. �S <br /> �STATION <br /> 7 )" 4. LOCAL AG'cNCYf01S'RICT' <br /> . � ' QRPORATtON 5, COUNTYAGENCY-BUSINESS TYPE rr 3.FARM �• r 5.CQMMERC AL r 7 :NGMOUAL [ 9• STATE AGENCY- <br /> BUSINESS <br /> 2.DISTRIBUTOR r +.PROCESSOR r a.OTHER r 3. PARTNERSHIP (� 7, FEDERALAGENCY- 402 <br /> 403 <br /> TpTAL NUMBER OF TANKS Is taeuty on inetan Ir Resemoon or ' owner of UST-s a vuol�c agertcr:name cr sucerwscr of <br /> REMAINING AT SITE ausdancs? =v,sx n,section or crfice wnien coerates age UST. <br /> ('ttns,s the comae oerson for the tarot r_c n:&) <br /> 404 ryesAM <br /> r No <br /> 11.PROPERTY OWNER INFORMATION <br /> PHONE 408 <br /> PROPERTY OWNER NAME 407 <br /> MAILING OR STREET ADDRESS 4M <br /> ,t LA Pt <br /> ZIP CODE 412 <br /> clrr 4,0 <br /> S-Fo c4,,- -v v1 <br /> PROPERTY OWNER TYPE r Z ,NOIVIOUAL r A. '-OCAL AGENCY f DISTRICT C 5. STA.c AGENCY 113 <br /> ���10ORPORATICN ( 3 PARTNERSHIP r 5. COUNTY AGENCY r 7 =EOERALAGENCY <br /> ////// 111.TANK OWNER INFORMATION <br /> PHONE 415 <br /> TAI OWNER NAME 414 <br /> MAILING OR STREE I ADDRESS 415 <br /> (a Ike 5 <br /> 411, ` STATC :a S ZIP cpoe Its <br /> I /�7.rL'A11' <br /> r <br /> rANOWNER TYPE 4. LOCAL AGENCY I DIS'RIC r > >,ATE AGENCY 120 <br /> K [�.,�2\iNON10UAL I. <br /> I [- 1. CORP^.RATION 1'CE 3 r�ARTNERSHIP r 5. COUNTY AGENCY • FEDERAL AGENCY <br /> CE Ent <br /> ccc r^ <br /> Call(916)322-9669 if questions arise <br /> i c <br /> W. LOCAL GOV=T MECHAMSM <br /> t, SELF tNSUR_D r <br /> :NO[CATE METHOO(S) c 4. SURETY BOND r T, STATE FUND r <br /> r <br /> r 2. GUARANTEE r S. LETTER OF CREDIT r 3. STATE FUND b CFO LETTER r 99. OTHER 4 <br /> r 3. INSURANCE r o. EXEMPTION r 9. STATE FUND b CO <br /> r 3. TANK OWNER <br /> C1ed one oox to wolcate wnlcn address smu,oe used for legal no"=aoms and maAwg, r FACILITY r oROPERTY OWNER - <br /> �, aI nobficatlOns and mailings w11 be S^m o me rarx C«ner unless oox 1 or'Is weckea <br /> t o <br /> Cart fxabon: I centty that tme information orowaee herein 13 true arta accurate to the best of my know}edge. 424 I NE <br /> SIGNATURE OF APPLICANT <br /> 1251 <br /> ® � .I L' F 42T <br /> NAME OF APPLCAN7(print) IDtnnA � <br /> � <br /> 4281 '-8 UPGPAOE CERT.F;CATE NUMBER(For:o W;sseOnIY) 429 <br /> $TATE UST FACILITY NUMBER(For local use orryl <br />