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UI IED PROGRAM CONSOLIDATED 4MlZI2IoY <br /> (3 <br /> � «����/ TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY (one page per sue) <br /> Paoe _ N _ <br /> ME OF ACTON NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(SP IY 0100oe- r 7.PERMANENTLY CLOSED SITE <br /> rYPE one CTI N local use MIY) r 8.TANK REMOVED 40D <br /> ;hwkr 4.AMENDED PERMIT <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> tU51NE5/5 NAAMM/E(/yS/a/me as FACILITY AME or DBA-Doug Busmns Asl 3 <br /> FACILITY ID x <br /> �" _ <br /> Zj�9 At FAC <br /> OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> IEAREIST 055 ET� 401 CORPORATION <br /> r 5. COUNTY AGENCY <br /> )USINE STYPE r 2 INDIVIDUAL I r 6. STATE AGENCY* <br /> r 1 GAS STATION r 3.FARMrCOMMERC AL F 3 PARTNERSHIP r 7. FEDERAL AGENCY 402 <br /> r i DISTRIBUTOR F 4.PROCESSOR r 6.0 HER <br /> TOTAL NUMBER OF TANKS u taukry M 4feun Resmatron a M awnar of UST u a ouoac agenLy.name of woarvuor of <br /> muBaMs7 Gi rasion eaCmn w o8ca whsZ operates Ne USi. <br /> REMAINING AT SITE '/1 (Th's is ma m =pars for ma�remora) <br /> 404 (,// low:F— r Yes o 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PHONE 408 C_�f <br /> PROPERTY OWNER NAME 407 <br /> G/ 1 STG T <br /> MAILING ORS ADD Eo 4f� O� QO <br /> S G STATE x/411 LP CEFEDE�AGENCY <br /> r 4. LOCAL AGENCY I DISTRICT rENCY 413 <br /> PROPERTY OWNERTYPE r 2 INDIVIDUAL r <br /> . CORPORATION r 3. PARTNERSHIP r5 COUNTY AGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 41 rD <br /> TANK OWNFA NAME 414 ) 5 <br /> MAILING OR STREET ORE 5 416 <br /> 4]l 51ATE 418 P CO E 41i <br /> CI J LTiL <br /> S� T �� <br /> TANK.OWNERTYPE F 2 INDIVIDUAL F 4. LOCAL AGENCY I DISTRICT F 5. STATEAGENCY 420 <br /> /Y1I CORPORATION r 3 PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDEMLAGENCY <br /> !/ R_RODAT\OF FOL <br /> TY(TK)HQ 4 4 I I I I I 1 Call(916).322-9669 if questions arise 21 <br /> INDICATE METHOD(S) r 1. SELF4NSURED r 4. sURET•BOND r 7. STATE FUND r 10. LOCAL GOVT MECHANISM <br /> F 2 GUARANTEE F S. LETTER OF CREDIT F 8, STATE FUND a CFO LETTER r 99. OTHER 122 <br /> [1S: INSURANCE r B. EXEMPTION r 9. STATE FUND 8 CD <br /> CMa Eos iM whkYl eEe ahaAe be ed fa k9al nolRmuuv W maJn9. r 1 FACILRY / PROPERTY OWNER r 3. TANKOWNER 423 <br /> al MtifiCaeons dM ma�lrtge will ce aMl 10 are Tank owner h0 2 UBckee. <br /> CeMloom' 1 ca Wt Na aaannaWn 9m heroin rs aae an <br /> I a�a1e Io VM east of my knowkO9e. �� <br /> GATE �2_Q/7 ilk. 424 PHONE 425 <br /> ` <br /> SIGNATURE OF APPLICANT ��j-'L ' 23 7 <br /> J <br /> 425 TITLE CANT 422 <br /> NAME OF APPLICANT WW) zz� M �2 <br /> STATE UST FACILITY NUMBER(For local use amyl <br /> f�/ _ 428 t998 UPGRADE CERTIFICATE NUMBER IFw tical usa aaY) 429 <br />