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07/27/2004 01:42 2098322@52 KWIKSERVEr((l PAGE 02 <br /> !+7b!14/Lt]r3t4 00;JJ .9VZOa4 r�rv�rti..rr•-� . <br /> uNTF'ED PROGRAM CONSOMA TED FORM <br /> TANKS <br /> U'r' DzRGROUND STORAGE TANKS- B'ACIL11'Y <br /> (aa:psgo per ai1,a) pegs„_,of,_ <br /> rwc or Aartv*I T.stew ere:n:RM+'t' '�.hlAtLMtnt..w►enn1T a cFT�trC-q l7e teteeftwxnanv 1'I 1.Yt:[UMANEN i 4T I:Lt1JJM s1Tz <br /> (Cheek eae item Duly) ❑e AWNDED PERMIT slYedy change loenl vee only lSul�l�_t`i.�_�_C1 g.tAN1C 0.Eth0ve p <br /> p 4111 IPORAUY SITE CLOSURE +� <br /> I. I±ACILITY/SITE MFO.RNATION <br /> BUSINESS 1VAINl;IS°meaTAClI f7V ttnMC nr1S8A_pvtn4Aa[mu M1 s FACILITY IDM ' <br /> • 1 <br /> V 'e.. <br /> gRL•ST CROSS$tRIrET 4t+t FAC ITY OW It TYP 4.LOCAL AGENCY1V%T=7* <br /> k Cu, a 1.CORroi4STiCPd �/' [1&.C0t1MYAGGMV* <br /> 1.QA5 ATTp 7,FARM U 5. COMMERCIAL XL7..INDIVIDUAL Q 6,STATE ACr.NCV* <br /> TYPE 2.DIYMIBU7.OR 0 4.PROCESSOR❑6, OTHER 4a3 b :1.PARTNERSHIP � ©7.FEDMAL AGENCY' 4a <br /> TOTAL"BER Or TANKS IsFntililyvnGsdnvttRefforvntionor •a[AwnArofu tsapuhliettgeney;nattxeTettperrisorer4i-iziutt,petalloeoroffim�ltloh <br /> REMIAININOAT517a+ rmsnondn? o*rrM•pdmU4T(Tbi°1*41te Mrthat+nwfneel✓tnnb+wnrtM.) <br /> 404 ( Yes N No 405 eoa <br /> 1T. IaROIPEATV OWNER INFORMATION <br /> Ap M9 <br /> r✓ PROPERTY OWNSIR NA MS PAT C--L- rn 1+118-S pt °i'I cf 9 3 S?b MQ <br /> NiAiLns OR S7R.EET ADDRESS <br /> r_ CRY _ iAll zip CODE +12 <br /> PRgpERTY OWNER TYPE I.CO1 PORATTON 2,INI:IIVIDUAL U A.LOCAL AGENCY I DISTRICT U6.5TATFA1lJbXGy <br /> 3.PARTNERSHIP 0 S.COUNTY AGENCY _ 7.FEDERAL AG£NCY 41s <br /> 111.TANK OWNER MO ATION <br /> TANK OWNER NAME 1ppqOf) 66 LI sla PWONC �'ZCD �y I �L7 +Is <br /> .II4 <br /> MAILING OR STREET ADDRESS <br /> CITY <br /> 417 STATE h 4u ZIP COM t^� 410 <br /> �._. c,IT f ,3 <br /> TAMCOWWO?TYPE. i CORPORATIOR 2.INUIVTDUAL ! 14.LOCAL AGFNCY1DISTRIC 6.STATE A45U 1CY 4211 <br /> 3,PARTNERSHIP Q5.00U.NTYAMCY C3 1.F9DERALAG£.'NCY <br /> TV.ROATRD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Ty R 44- Call 916 322-9669 if estior a prise 411 <br /> V.PETROLEUM EUM UST FINANCIAL REWONSITfILM <br /> 1NDTCAIT MET}IOD(a) d I.SEI F-IRSUREA Cid•SVR@TY BOND Q 7,STATE FUND ❑10.LOCAL C VT MECHANISM <br /> (3 2.OUARANTM 0 s,L'69'T611,pF CRk17IT ©s.STAIrt,r JND&CFG UTTER Q 90.Onmit: <br /> { 3,INSIJRA1+1G1: ©A.F,XEMPTIOr4 ❑9.NTATC FUND A CD ' <br /> VI.LFGAC NOTMICATTON AND M AMINC.INC.ADnItt%4-4k <br /> [-torte one up s tedlesu which eddcet s Ingula IN Lewd M w1p.t�w.r a�tons and ma ling. 4 <br /> LtgTlne0cetiwdodtMmUlswillbesum tothe lnAmomeTWien b6icIatIistkalmd. L]1.FACIUTY t17.PR0PERTY0WNER Q)JAPIKOWNIiR <br /> V11-APPLICANT SIGNATURE <br /> Ctttlf&4tiV1t-14rodIFy t4�+I tUr 1itMne.ti+o.�rOr;deJ Ixse[n�n aAd ttaautete eo the pwT aFtrtT knvKtedpe <br /> �...s NATURt OF APPLICANTDATE ° rnowG 4Is <br /> 7y� Rr- <br /> NAIVE OF AFPLICANT(PAnl) .._.... I. A <br /> '��� �•� d��l yrs ��, � '"� <br /> STAIR UST FnCILFfY NUIVII3T+A/!°T ls�+i.+r---1211 <br /> 4111 1909 I1PCT(ADFCFRTTAIP'0L11;`NtWAF.R�eMta�nT•+•nnWl <br /> UPCF(1199 revised) Formerly SWRCB FaM A <br />