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. 01/08/2004 08:23 20946836 FIFTH FLOOR PAGE _.7
<br /> UNIFIED PROGRAMSOLIDATED FORM
<br /> TANKS
<br /> UNDERGROUND STORAGE.TANKS -FACILITY t�
<br /> (One page per s te) Page of ^
<br /> TYPE OF ACTION ].NBW PERMIT El 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION []7.PERMANENTLY CLOSED SITE 400.
<br /> (Check one item only) 0 4,AMENDED PERMIT(Specify ebange) ❑S.TANK REMOVED
<br /> ❑6.TEMPORARY SITE CLOSURE
<br /> 1'9
<br /> 'II �,� 1 1 I,:1 II •
<br /> •�11 1,� r u q'n ' r 1`1 i tL I?I�LCA�`�Sf,,l�'I'�'E',•_Il?FPO�I����1�E <,�ir (1 1
<br /> 1 r,
<br /> I 1 r I 1 Iu rru '
<br /> BUSINESS NAME(saw asFAourrNAM orDBA-Doicl;1Iw;4essAs) 3, FACILITYI
<br /> GYAS S i / a� lN. 1W i t -L J
<br /> NEAREST CROSS STREET mi. FACILITY OWNER TYPE [14.LOCAL AGSNCY/DTS',RICT'"
<br /> MA#Q T HF.`( "AD ❑1.CORPORATION ❑5,COUNTY AGENCY*
<br /> BUSINESS i.GAS STATION [3 3.FARM ❑5.COMMERCIAL 403. 2,INDIVIDUAL ❑6.STATE AGENCY*
<br /> TYPE El 2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER 3.PARTNERSHIP ❑7.FEDERAL AGENCY*
<br /> 'DOTAL NUMBER OF TANKS dQ6• Is faci[ity ou Indian Reservation 403. -If owner of USI is a public ascricy:name of supervienr o£division,reealou or M,b.
<br /> REMAINING AT SITE or trust lands] office which operates The UST. (This is the contact person for the lank records)
<br /> Z' ❑Ye3 VNo D V
<br /> ri',' yII 11{a r'�.1/I If.r111`lu rill liil ii;l,l�i'1 {'E,' TYMovEa�l,mo ;z'or�,r (rl lllr•:i' r, , Ic;. Ir I;.n6; I,rl ,I'•77
<br /> ..,.
<br /> r � f
<br /> PROPERTY OWNER NAME 4U7•
<br /> ONE
<br /> J OS DA'N QTR-A�I�j 0 0 d 0 _
<br /> MAILING OR STREET ADDRESS 40.
<br /> 3'317 -t=L I NT M o N T P R-/✓S
<br /> CITY _ 410. STAT,EA 411• 1 ZIP CODE ---- 41?.
<br /> PROPERTY OWNER TYPE Ll 1.CORPORATION _,INDIVIDITAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY
<br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERatL AGENCY _
<br /> l ' X. r . d
<br /> I 1 ''1 Il it u❑ ,nn.1�,,..nru 1 I , "1 r , I' ,' f'" r.,r 1 nl' , .11(n arc lilriil n1 I, 'i r; li 'i1i'
<br /> r.l ualu YI ,Inl 1 a, n, 1 1 1 I
<br /> ��„ativlv�n+�?oirmA, roNl
<br /> TANK OWNER NAME Ora. PHONE r 415.
<br /> ,Joie b AN Gr-t'R-yk0 [14-00)W- 00o) -__--
<br /> MAILING OR STREET ADDRESS 416'
<br /> 3$l -7 FLINT MONT J-)R-lVj�i
<br /> CITYS^ Q S 417. STATE Ota. ZIP CODE q-5-! ^ --_-419.
<br /> IJ J
<br /> C-jr
<br /> TANK OWNER TYPE ❑1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DTSTRICT ❑6,STATE AGENCY 42�.
<br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY 7.FEDERAL AGENCY
<br /> at 1i.3i 1'i�i Ile.Il I¢Ilr �: r 1!,, �- 1 .,r '- r. 1 ..,.' r`1 r' � (.. r.,ndl 1;1,1 onnm run r u„�.,,rlr n+-.:rol�,Mena r n•-„'1 rf11 r 1 1,, I.'.. I I
<br /> ,.4 '. QRACEFEEIl�CCOUNT NUMEEk1 r 11 11,11,1
<br /> Ic,E:� , 1:uu•1..fl 1.1 -,7', •I•, ..r,,... ,u,l,r .Lu,11wl,,,y.r,,,.n111„u.ou,,,:u•1•r>I 1,r,r' ._�L__.s�
<br /> TY K HQ 44- 1 1 1 Call 916 322-9669 if questions arise 411.
<br /> 4 y.� ! 1 •�, 7�r/h p i. 1 1p�(,�7(�rrl l:}1�"r ,(1(I P'/ 1 1 li(I 1 i I r l
<br /> 11111 r1'i 1 0111'
<br /> .. f 1�i i r li 11{ i�{I 1 1!I.i.1 ! t.-,1: �'+la: O� ..V 47 .{' A4\V WI .�{J1�17�].V YID I"w�Jr I' 'i•ilii 11�), 1 l Ili II I)II,I I. `, it I I r, 1 ii
<br /> INDICATE METHOD(s) ❑1..SELF-INSURED ❑4.SURETY BOND7•STATH FUND ❑10.LOCAL,GOVT MECHAl`ISM r;t
<br /> Ll 2.GUARANTEE [IS.LETTER OF CREDIT g.STATE FUND&CFO LETTER n 99.OTHER:
<br /> ❑3.INSURANCE ❑/�6..EXEMPTION r/ ❑9.STATE FUND&CD
<br /> 11 IE�'� 1111 1 1 11 1 1 11)1 11 I 1/I LECA, \ / �{'.. �.. P I( 1 'AN
<br /> �.-
<br /> I,; I r A"�'NOPE'A1�1�1�112iI�;Il�T��AljI1IJ!1RESS11
<br /> 1 r:sr„1 1,:,,,1 ...I. 1 r,,1 r,rl,l 1,11,r ,.11 r 1:•I,l` r
<br /> Check one box to iodieW Which address should be used for legal no4Eications and mailing,
<br /> Leash notifications and mailings will be sent to the rank owner unless box 1 or 2 is checked. ❑ I.FACILITY 2. PROPER'T'Y OWNER ❑3-TALK C'WNER 4:;'•
<br /> 1~
<br /> 71
<br /> �tr r'II}dII fln n, r11 r Vii' 1 .I� 1i I I, I r 111.1 I 11 r ill 1 `'; , o'.,
<br /> '] 1APTcvsz� .�'uI
<br /> Cenirleation_i c 'fy that the information provided herein is true Bald accurate to the beg of my knowkdgc.
<br /> SI APPLICANT DATE y- 424 HON 4=T
<br /> 03 o�- 4-vs)W-0a0q_�
<br /> NAME OF APPLICANT(p ) 416. TITLEN APPLICANT
<br /> 7ATE UST FACILrTY NUMBER(Agency u:e any') 429. 1998 UPGRADE CERTIFICATE NUMBER(Agettcyuse otayj
<br /> e Data Eletnent 1,above.
<br /> UPCF Hwfivre-a(1/99)-112 hffp://www.anidoes.urg Rev.Q1,16/00
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