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UN•EO PROGRAM (; 04SOL.l0A7c7 r <br /> n�yf i I ANKS <br /> UNDERGROUND STORAGE TANKS - ;FACILITY <br /> cr:e--age zef=e) <br /> „oc 3F AC7CN •4eN Si—,=PERMIT 1 3.ReIE`NAL xRMIT .._::•NGC:F NFCRIAA-CN��eey^.ange- _ x�MANEN7S.Y:�^,Sc7 SITc <br /> .:Gv�secrort _ j. "ANK.1EMCUEO x70 <br /> L + AMENCED PERMIT _ <br /> i i._MPCRARY ii ._.cSLRE <br /> 1.=AC:L'i!!SI i c;NFCRMATICN <br /> 3US:NESa NAMEI rAC:L:'0= <br /> 'Same as?AC: orOSA-`on4 3us+ness AS) <br /> f l �t M 6L >cu wNE4 P= + COAL AGcNCYrOIS7R C'-' <br /> NEAREST rR055 3 RE= -01 / N <br /> --:RPCRATION , 1 i. COUNTY aGc'vG:' <br /> 3USINESS-P° 1 GAS STATION t 3.=ARM r 5.cCMMERC:AL (k-ff 'NOMOUAL i l i. VATEAGcNCr <br /> 3.•c15TR18UTCR � + ?40CrS5CR r x OTHER � � 2.*ATTIERSHIP I l7. F_0E3ALAG'cDIC`." 402 � <br /> +03 <br /> ICTAL NUMBER OF TANKS 's racer on�r+man Reservaoon or "t-.vKw cr UST s a mAuc agency:name a aaosMscr PC f <br /> nuoanas7 zvm3 i seoon 'r�fsa vni'm coaruc:.-s UST. <br /> ,REMAINING A T STC r` (` �ihxt,s To wear Pssart fpr Te lane remlCL) <br /> AM <br /> 404 3I <br /> 10 f4cs <br /> II.PROPERTY OWNER INFORMATION 1 <br /> PHONE +oe <br /> ARCP= TY OWNER NAME 4407 U <br /> I <br /> j�wlunc OR =,STaEAOORESS s09 i <br /> wcaoE a,z <br /> FC; a10 f <br /> Q cg <br /> ?4cPERTY CWNER TYPE i Z NOMOUAL ! +. '_CC:•LAGcNC`.'tO:S RICT l 3. STATEAGE.NC. 41 <br /> a <br /> :ORPORATICN PARTNERSHIP i COUN Y:Gc'ICY C �E?ACAGc'+CY <br /> i I <br /> t <br /> III.TANK OWNER tNFORMATICN <br /> ' 24ONE +15 <br /> ` ,)WNER NA11j I `P <br /> >AArL:NG OR STREET ADDRESSA-i= <br /> ZI?'_CCE 419 <br /> I it <br /> TANK OWNER TYPe l� tr�N09V10UAL + lGCAL.:GcNC!;:IS-71G" l i. .iA:C.iGG4C! a20 <br /> (� t '3CRPCRATTCNf i PARTNERSHIP ;- i COUNT' Gc?K Y 7ERAL-4GF-NC! <br /> I <br /> 421 ; <br /> IT„ )HQ 14 I a i _ Call(916)3V--9669 questions arise <br /> I i <br /> 11 oCrr� <br /> R -1 <br /> NOICA.c METH00(S) [ r. 3E!.°.:NSURED r J. SURE Y SONO C i. TATE FUND C '0 _OCAL xOV.T MECrIANISM <br /> 1 <br /> )- <br /> Z. GUARANTEE i OF CREDIT I- 3. 57 ATE PJNO d O L=i'cR r 99. OTHER: 1` I <br /> i <br /> �NSURANCS C a EXEMFnON 3. STATE PJNO a CO <br /> vi I e -1 Dee <br /> 1^ �RCPE"1TY CWHER C 1 TANK OWNER 'n <br /> C.'+eac ene ppx'o-naface wnKn a=MSS snout be used for regal npp(+opoit3 aM masi+q. .. FAC:UTY - <br /> al rolrt cOnem an0 mae s nu oe sent 10 me ryes;v+n9 ;mess 00.?or' ceoc <br /> G <br /> Vtl Pot�f'SeLLSI>;.M1L'IIBc I <br /> :anrt+C7UOn' I Cent/mac me,nfoMaopn xovicep heron o arta ana acarine to me cast d my 1 ) <br /> 3 1 to �r I +z. <br /> SIGMA^ UC;RE•JF APP1fiT <br /> +SI 'TiL OF,A1Po� GI•NT^/;n +27 <br /> IIII <br /> 1 NAME::F APP!:CANT;pnn 1*,&, I/J :C.(J•�f}. a291 dUPGRAGE c4T:F::UTr.vUM864 y.o Oso0 +� <br /> 75T FAC:L:TY.NUMBER r.'Or-4c3J use crvy) <br /> i <br />