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11/1312009 10:18 2008873409 KAREN ARNAIZ PAGE 03/04 <br /> UNoul)PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TAIXK �)I <br /> OPERATING PERMIT APPLICATION^FACILITY INFORMATION <br /> (oar fwm Per fkdhty) <br /> TYPE OF ACTION ❑ In NEW FEMNI T ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (ch"kOSQ is O w 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACIIJ Y CLOSURE 13 9-TRANSFER PERMIT <br /> "C•. .u•.. .•4.,..y}:.,.,:...-�\1��.�,hr,.,,2.•.+ •..v.".Y"`.::.,f..A '1•.,`k'. .si •:;/�. ir�. .';xf.:.«.�;:: <br /> TOTAL NUMBER OF Ta AT FACILITX °01' <br /> FACILITY iD# <br /> (Apm y Use O dv) <br /> 3. <br /> BUSRMSSx (saamas]FAC NAtta« - p As) <br /> o <br /> BUSID ESS SITE ADDRESS ► ` CrI}( 104 <br /> FA&I TY TYPE I-MOTOR VEHICLE PUPIM ❑ z.Fm DISTRIBUTION 40' is the facW vested on b4ow Reservation or ' <br /> 3.FARM .PROCESSOR <br /> 6.oTFIFR To*loads? Toa No <br /> :.., <br /> pROP>rit7 Y OWNER NAME 497,.1PHONE 41 <br /> MAR24G ADDRESS 40l. <br /> Cirry r 410. STATE 411, ZIP CQDE 412 <br /> TANK OPERATOR NAME 426 t PHONE arses <br /> MAII ING ADDRESS <br /> STATE ZIP CODE 4 ' <br /> TANK OWNER NAME I su PHONE t15 <br /> MAILING AnnRFs�. �. la <br /> C i 4lZ $TA 41� ZIP 419. <br /> ,f!�Xay\-OWNER TYPE: ❑ 4.LOCAL AGENCY/AISTRICT ❑ 5.COUNTY AGENCY ❑ &STATE AGENCY �m <br /> ❑ 7.FEDERAL.AGENCY 9- <br /> v <br /> . <br /> '.: . ....: .' .4n_„ ! ,Y;.• �t� �Rte.. .,...r.^..s• — <br /> .... Fa <br /> qy(M gQ 44- Cau the stale Bond ol'Egm 4zwom, d Tac Division:inhere an queniow 471. <br /> :.p:. K: '.�« ':^ ;;��n�;,,,.�i.".,,. s'x,': ;;xr„ ..L•:i" •,.°•... '!:+ <br /> ":.i'a>.•: .r..• ,yv.'.,:':.;"'' :',f..S°�" ,'.u••'; <br /> :+ti �� 4; <br /> issue perimdt sod mad Iegat nouficstions eud msilhlps to:,f Q 1.FACII.TIY OWNER. ❑ <br /> 4.TANK OPERATOR <br /> 3.TANK OWNER Q S.FACUTY OPERATOR <br /> 5UPEltVL40R OF DIVISION,SECTION,OR OFFICE(Required For Pabtic At mise Only) 40k, � <br /> CI.'E'fMCATION: I tl3titt the ilatdrmarlou 11e�$ n xxd In fsyll with ; ' <br /> APPLICANT SIGNATURE ,& DATE PHONE t <br /> AP,PLWANI•NAME(print) 4RGAPPLICAI 4p <br /> r� <br /> UPGF UST A Itm(11=7) <br />