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r <br /> L 71EO PROGRAM CONSOLIDATE' )RMX <br /> PAN <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> rP:OF ACTION K,.NEW SITE PERMIT 1 3.RENEWAL PERMIT �.i.0'A.YG2 OF 1NF0RJVLA CCN iS0eo.jC,ange- r i.PERMANENTLY <br /> fGt�c t are item oNA AMENDED PER.NfT <br /> y) (_ cew use only! r d.TANK RE.MOVEO CG <br /> [� <br /> [-i._`.IPCRARY SITE CLCSURE <br /> I.FACILITY I SITE INFORMATION <br /> 3US:NESS NAME(Same as PACILITY NAME or OeA-00 N 3usness AsI 3 r C u T" 0 s <br /> NEAREST CROSS STREET -LOt =AC:UT'OwtyER TYPE [ s. LOCALAGE. Yr01S'R:C' <br /> - 06 /� I. ;;CRPORATION <br /> `F Z r 5. COUNTYAGENCY' <br /> 3US1NES5 TYPE COMMERC AL NCMOUAL <br /> I GAS STATION r 3.FARM +/V• C 6. ST ATE AG'cVCY' <br /> L OISTRIBUTOR r +.PROCESSOR r o.OTHER r 3 aARTNERSHIP l r 7. FEDERAL AGENCY <br /> +03 <br /> TOTAL NUMBER OF TANKS :s aCuty an InCtan Reservaaon a r owner d US s a xr.c agerrr nacre a st.oerwcr..t <br /> REMAINING AT SITE s—'•? z..sw^sec=n a^.i+ce wnrat eaerares a•.e UST. <br /> (Thu u ase cone arson for Ine tarn r_cA,=) <br /> sr,4 u r Yes +05 A06 <br /> 70 IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 y� � ?HONE =C8 <br /> WILING OR STREET ADDRESS 4C9 �,� � ,'1 -•�7"�� <br /> `7 57 12 iL. � I� S� f / <br /> CITY Ata .� h - I STATE 41.1 r ua Coo_ 2 ?c <br /> PRCPERTY OWNER TYPE NOMOUAL r S '_OCAL AGENCY!01STRICT r 8. STATE AGENCY 1:3 <br /> CORPORATICN PARTNERSHIP r 5. COUNTY AGENCY r 7 =EOEPALAGENCY <br /> Ill.TANK OWNER INFORMATION <br /> I TA:tK OWNER NAME 414 D A ?HONE sty <br /> 1AA1L:NG OR STREET AOORESS +,6 7 �p .- � pc-� �`T � /.r1 Ij` � f,2� <br /> C7T' /4//^ e 1 tl� v STATE Eta Clacc�OO,E e is <br /> �1 t12- � I �` r 1 3 � <br /> I TANK OWNER TYPE r 2 tNOMOUAL r a. '_OCALAGENCYIOIS. r STAT-c AGENCY +20 <br /> I CORP.RATION r' 3. PARTNERSHIP r S. COUNTY AGENCY r 7 F=7ERALAGENCY <br /> I e TK)HO q q I/���jl 7I Call(916)322-96069 ii questions anse <br /> �[ I o=Tpflt C 4 <br /> :NOICATE METHCO(S) r I. SELFaNSUREO r A. SURETY BONO STATE FUND r t0. LOCAL GGV�T MECHANISM <br /> r <br /> Z. GUARANTEE r S_ LETTER OF CReo r . STATE FUNO S CFO LET= r 99. OTHE.2 <br /> I3. NSURANCE r o. EXEMPTION r 3. STATE FUND 3 CO <br /> K n C �— <br /> IF �ecx arra bax to mcieate wnra,address mould be used far regal ncufieatwru and ma..r p5,; FACILITY r Z oROPERT 04�N'cR r 3. TANK C'hNER <br /> -,c-,- ,,rotdieatrons and mal inns II be sent o me tarn owner r_ntess tax t cc q C'ecxed �! <br /> , o <br /> Cer;rcaucfr. I cantly Nat Ina of align crovCsd nceim is cue ane ac wale to 09 best of my Yncwfedrre. <br /> SIGNATURE OF APPLICANT : I 7ATcc ^ 42s I P? © `f� � <br /> NAME OF APPLICANT(pnnr) 3251 TL=OF APPLICANT 427 <br /> t <br /> STATE UST FACILITY NUMBER tFor.bew use orw) +291 'z-1--a UPGRAOE CERTIFICATE NUMBER(rCf.o=use only) 429 <br />