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Ask 0� . <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> V"ERGROUND'STORAGE TANK J <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (one Sona par£aoilitY) <br /> aoo• <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION [} 7.PERMANENT FACILITY CLOSURE n /� <br /> (Cheek one item only) 3.RENEWAL PERMIT [] 6,TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT �( <br /> ,.''.•.�:•�..r'-is r.,•y.... ....: . <br /> TOTAL NUMSHR OF USTs AT FACILITY a0a' FACII.ft'Y w# <br /> (Agavy Use fib') <br /> BUSINESS NAME( FACSLMNAMEorDIA-Deiatto AS) &nl <br /> loo, CITY <br /> Bvsuvi3ss srrE D ss 1 <br /> N1 DOgn VA Lal <br /> FACILITY TYPE W I.MOTOR VEHICLE FUELING ❑ 2 FUEL DISTRIBUTION ' Ts the thcility boated on RoswV9 04 er <br /> [] 4.PROCESSOR 6.OTHER Trust &? ❑Yoe ° <br /> 3.FARM <br /> ?.;.•.- PHONE Tape, <br /> PROPERTY OWNER NAM / <br /> M a S� 411, 22 ' <br /> CITY alo' STATE <br /> �• <br /> TANK OPERATOR NAME),4 -1' 43 W <br /> PHONE <br /> MAILING ADDRESSP/ 43VA <br /> � <br /> CITY aSTATE f 4u4 Z[P CODE <br /> ,.: <br /> TAMC OWNER NAME 4. PHONE y as. <br /> 416. <br /> MALLBYiGDREss�� <br /> CITY plo417. STATg 418, ZtP CODE 419, <br /> /'o l / 4 <br /> OWNER TYPE; ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTYAGENCY ❑ 6.STATE AGENCY 44' <br /> 137,FEDERAL AGENCY $;NON.GOVERNMENT <br /> qu <br /> a <br /> if th <br /> Di <br /> B <br /> S <br /> TY Cm)HQ 44- 0 °f RW T <br /> Coo the tats Dowd Equalia�dan. aDIA", ere re e�atimu. <br /> ;, .. <br /> Issue permit and send legal noNEoaticm and raalliaga t°: E3 1.FACILITY OWNER <br /> VF 4.TANK OPERATOR <br /> (33.TONIC OWNER ❑ S.PACILiIY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requuad.For Public Agodo Only) <br /> CERTIFICATION: I cati bWo b tea aacnra and' tt111 lienee t i i ass. <br /> DATE <br /> APPLICANT SIGNATURE <br /> } � asp <br /> APPLICANT NAME a ' APPLIC IT r. .,.� <br /> 17 <br /> UPCF UST-A Rev.0=007) <br /> 60 'd Z0:91 60OZ L $nV 016199V60Z:Xed 10d 10 NVA <br />