Laserfiche WebLink
I:I UNI. -D PROGRAM CONSOLIDAT:O FOKI <br /> .I <br /> TANKS ' <br /> UNDERGROUND STORAGE TANKS -- FACILITY <br /> ` .one cage per sate) <br /> it <br /> Page - 7I _ <br /> T,PE OF ACTION r t.NE`1V SITE PERMIT r 3.RENEWAL PERMIT r B.CHANGE OF INFORMAT:CN i$oeotr ctange- T.PERMANENTLY C%OS=J SITE <br /> (C::scx one item only) 4 AMENDED PERMIT aCy ww only) r 8.TANK REMOVED 4M <br /> [' <br /> (' ,M?C..RARY SITE CLCSUP.E <br /> I.FACILITY I SITE INFORMATION <br /> 13USiNESS NAME(Same as FACILITY NAME or OaA-Oomg Business As) 3 FAC:L:T`:'0 s <br /> 111 NE:.REST/CRO SaT 40t FAC:UTY'Jv.NERTYPE I [- 4, LOCALAGENCIYIDISTnIC�_ <br /> - <br /> REE <br /> ;RPORATION I- 5. COUNTYAGENCY• <br /> 3USINESSi7YPE GAS STATION r 3.FARM F 5.COMMERCIAL /SSE :NGMOUAL [ 9, STATE AGENCY- <br />' r 2.OISTRIOUTOR I- +.PROCESSOR r o.OTHER r 3. PARTNERSHIP r T. FEDERAL AGENCY• 1C2 <br /> 403 <br /> 'DIAL NUMBER OF TANKS .s:acery an ItWtan Reservatgn ar 'K Avner of UST's atq agener:name Cf suoenrucr x <br /> REMAINING AT SITE ausoarws7 vrvis om.secwn or e.'4r..e wnicn coerates tre UST. <br /> (Ties is trio contae arson for Ute tarot r_exrs) <br /> 404 r Yea Na 105 106 <br /> 11.PROPERTY OWNER INFORMATION <br /> PHONE 108 <br /> PROP TY OWNER E 407 <br /> MAILING R STREET AOORESS +09 <br /> —STATE4,.i ZIP COOE 412 <br /> CITY 410 <br /> pRcPER OWNER TYPE NOIVIOUAL C + LOCAL AGENCY I OISTRIC' C j. STAAi c AGENCY 113 <br /> CORPORATICN 3. PARTNERSHIP r5, COUNTY+GENGY C T FEDERAL AGENCY <br /> I III.TANK OWNER INFORMATION <br /> ?!TONE +t5 <br /> p,Ar4K=OWNER 114 <br /> D fS <br /> /— • 9/ <br /> :NG OR SIRE`=T ADORES +t6 � <br /> ( <br /> STATE 48 i itPOE +19 <br /> c:r• +17 �1�11FV <br /> TANK OWNER TYPE tNONIOUAL C +. LOCAL AGENCY I OtSTRICT C S. STATE AGENCY 420 <br /> I. CORPORATION 3. PARTNERSHIP C 5. COUNTY.+GENCY 1- FEDERAL AGENCY <br /> i f TK)HO 4 a I I I Call(916)322-9669 if ct estions arise ` <br /> p c <br /> INDICATE METHOO(S) r t, SELF INSURED I'4. SURETY SONO T. STATE FUND C 10. LOCAL GOVT MECHANISM <br /> ° r 3. STATE FUND a CFO LETTER r 99. OTHER. <br /> VGUARANTEE r.S. LETTER OF CREDIT 42< <br /> 3. INSURANCE r 5. EXEMPTION r 9. STATE FUND 3 CO <br /> F <br /> C1eC.K one bort to indicate wnicn address snould IM used for iega1 notftatxxu and matting, r I. FACILITY r 2. PROPERTY OWNER . TANK OWNER 12: <br /> eatificatibris and marlin s wel be cern to the tarot cwner unless cox 1 or 2 is decked. <br /> t 0 <br /> Certtfica-ri: tfy the information aroinaea herein Is true and accurate to the best of my knawMtlge. 12 <br /> SIGNATUR i 7A = / / 424 ?HONE L"f <br /> �//.�• 2G• Z eb <br /> NAME O T(pin �( x251 -tTL=OF APPU Nr7 +27 <br /> O�+/N <br /> STAT-z UST FACILITY NUMBER(For:acsl Ilse onrv) 4281 'z-Q-3 UPGRAOE CERTIFICATE NUMBER fFcf aaCa1 use Only) 429 <br /> i <br /> At <br /> P <br /> .a <br />