|
04/18/2013 11:46 2093344684 05032 P.006 /020 (,
<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERAMG PERNUT APP,LICAMN—FACIUTY INFORMATION
<br /> (One form per faality)
<br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5,CHANGE OF INFORMATION [3 7.PERMANENT 4on
<br /> E�Ci`Oam�°" ❑ 3.RENEWAL PERMIT 6.TEMPORARY FACT ITY CLOSURE ❑ 9.TRANSFER ERMTCILITY CLO$IJRE
<br /> _— —__._. ....,........._. ........ �..• q�.e.. ._.iri ��.. .. .... iii r;:.
<br /> TOTAL NUMBER OF USTs AT FACILITY 404. - -
<br /> FACILITY ID
<br /> (ASmcy Use Only)
<br /> BUSINESS NAME{ FAC¢1TY Mnaa�a 4HA-DoogElutioen/Ae)
<br /> RUSNESS SITE ADDRESS 103• CITY ,oq
<br /> ` N <03 .0,7 D�
<br /> FACILITY TYPE I•MOTOR VMCLE 1UELING ❑ 2.FUEL DL5TRIBUTTON 400, Is the facility Ioc9tcd on Indian Rema atioa or 405•
<br /> 3.FARM 4.PROCESSOR 6,OTHER '�St hos?d ❑YeS ❑No
<br /> .....,....-_r. •_______... ,,;•.::�:.: Inn::;.^^:«....,....
<br /> _..............r ,_•zap..,._ � ...... ...�
<br /> ,...,•.....W' .._...._._--••-r`"�~i""'-^'-n,.__-•_•_-.- � ..:. ...... ....y.«...�;•_.. .,..; ..rim:_" _
<br /> PROPERTY OWNER NAME
<br /> PHONE 41t
<br /> MAILING ADDRESS
<br /> I W r /v - orl"? 409.
<br /> CPTY �} 410. STATE 4E I E
<br /> 4
<br /> ( J
<br /> 1
<br /> u:�x,�AWbq:e-�-•..ra......... r n.::t"�r.,:...:.,'.,1.._.,_....... ••-...,(7a11k!C.�:e:: _ _
<br /> ..:_-.a�•tr•.._..rt..,rynr -,..,1`:n:.,,_... _ ,sa •_I;Vcr..,r,_..,.✓.,..;.,, - -
<br /> f m IMI..........�.. �U ++•__ f+(urh•-�....;_.....;.r,r;_...;L �.:' -
<br /> ... -
<br /> TANK TOR NAME -PHONE428,i• 421,1
<br /> MAILING
<br /> �-�-
<br /> MAiLiNG ADDRESS 4
<br /> ?7/ /v
<br /> CITY STATE 4�8 S GIP E 428.6
<br /> ._a...�,.h.;yrr,_;..,. 1...,,.....,. .n:n ,_r.._.a�..:;,y...,.,..•-� srr.:.
<br /> -
<br /> ,,.,_-. •_—;�:-,>..Jgrca::...aSr,4:«.r.3s:n(-r................ .....,r,« ,,r..� � - _
<br /> .r:
<br /> TANK OWNER NAME 41e. `PH,.,��0�lyN/4]E' �/✓j'��" N�� ,./y J%�-�µ
<br /> 415.`.
<br /> MAIIINC AD ppp��/
<br /> 416,
<br /> GI 417. STAT 4iS. ZIP(.ADIi � a19.
<br /> of 1
<br /> OWNER TYPE: ❑4.LOCAL AGENCYlDISTRICT ❑ 5.COUNTY AGENCY ❑6.STATE AGENCY aza
<br /> ❑ 7_FEDERAL AGENCY ❑'8.NON-GOVERNMENT
<br /> W ._...
<br /> R.
<br /> TY(TK)HQ 44- - dim queStioa. 421.
<br /> :.._....,, ... _,._.r .. ... cola
<br /> ....tett Goad of Egaal
<br /> F
<br /> 8R VISII511
<br /> eTe
<br /> �y :
<br /> ❑ 4.TANK :..,.&RA»:.:.:.•.....,�: :;w•.,,:
<br /> Iss�x pencil snd send Legal nvtiflcations and mailings tq: ❑ 1.FACTVI Y OWNER OP TOR421
<br /> 01-TANK OWNER ❑ 5,FACILITY OPERATOR
<br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Recpmd For Public Agencies Ody) 40&
<br /> cr
<br /> .::. � .•. me ... '.Y::W:T:::::- ?:•aC., --=a�Yn:'::'
<br /> CER'fIFICAT1dN: i � , • —
<br /> ,-eiQ is Dare°rd and in fall.:.... .:.r:.a;,;,.k.;..„,..,„...,.,,_.:.:;,•.,::
<br /> 11 vided he te. ODEII with 1
<br /> APPLICANT SIGNA q / 42l InION5APPH
<br /> .
<br /> T NAME(print) 4 APPLICANT TPi I,$
<br /> Own
<br /> UPCF usr.A Rav«(I2f2W7)
<br />
|