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v UN ED PROGRAM CONSOLIDATED <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS <br /> (one pagep / ' <br /> TYPE OF ACTION I. 1.NEW SITE PERMIT ��// Page _ of <br /> (Check one item only) )- 3.RENEWAL PERMIT F 5 CHANGE OF INFORMATION(SFsI change- :16 PERMAryENTLY CLOSED SITE <br /> r 4.AMENDED PERMIT laDal use only) j= - OVEO 400 <br /> ISI <br /> 1' 8 TAf9 <br /> C 6.TEMPORARYSITE CLOSURE I I I <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Going Business As) 3 FACILITY IDT <br /> IUDIPjcvl 5 cCX/M-X OY'si9N TD Gl�� CC{�i <br /> NEAR CROSS STREET `. <br /> AC ITY <br /> 6,14 <br /> 55,T,A''O'7vJ rr FIV 1. CORPORATION PE ` /r AG'cNCY/DISTRICT' <br /> BUSINESS TYPE r f.GAS STATION r ;.FARM F PERMIT, .GE4`4� <br /> r 55 COMMERCIAL 2. INDIVIDUAL 5. COUNTYAGENCY' <br /> T 2.DISTRIBUTOR I 4 PROCESSOR YK6.OTHER C 3, PARTNERSHIP F 6. STATE AGENCY- <br /> TOTAL NUMBER <br /> 603 r 7. FEDERAL AGENCY- A02 <br /> REMAINING AT Sit Is FI on Indian Reservation or 'If owner of UIs a ouDIIC agency ST name of supervisor of <br /> TE TANKS ,nattancs? - <br /> oimsion, eForn aferawhiU operatesthe UST. <br /> 604 / (This is the wmacta person for the lank resorbs.) <br /> r Yes, r No 405 406 <br /> PROIt. PROPERTY OWNER INFORMATION <br /> ,,PE�,R{TY OWNE/R,N�A/M�E �7 e/C/�9W <br /> uxme V V71--k— Vf SjTlt� Z50,4,4 UI/✓ �HO�NEE�� 408 (, <br /> WMAILING OR STREET ADDRESS 409 `-✓V �^� / 9 Z-6 l/ <br /> ZD D/�'f� SAscJ T4 Iit/ %— <br /> CITY 410 <br /> cTsr ///Tl1N STATE dt, zIP c0D 412 <br /> PROPERTY OWNER <br /> QY O ER TYPE - ??5-7-0Z <br /> F✓1'. CORPORATION r 2. INDIVIDUAL F d. LOCAL AGENCY'DISTRICT C 6, STATEAGENCY 413 <br /> 13, PARTNERSHIP F 5 COUNTYAGENCY 17. FEDERALAGENCY <br /> I <br /> TANK OWNER NAME 414 Ill.TANK OWNER INFORMATION <br /> GUD/YD9 <br /> MAILING OR STREET STREET AODitESg a'E <br /> clrY l /ll <br /> 4vJi(� <br /> ;;I/ k /v STATE 418 ZIP CODrE 419 <br /> TANK OWNER TYPE9J � <br /> 4'1. CORPORATION r 2. INDIVIDUAL F a. LOCAL AGENCY l 0ISTRICT k 6. STATEAGENCY 420 <br /> r 3 PARTNERSHIP F 5 COUNTYAGENCY I 7. FEDERALAGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise <br /> 421 <br /> INDICATE METHOD(S) [' 1. SELF-INSURED F 4. SURETY BOND <br /> I 2. GUARANTEE T 5. LE TER OF CREDIT T 7 STATE FUND F 10. LOCAL GO MMECHANISM <br /> r 8. STATE FUND 8 CFO LETTER <br /> r 3. INSURANCE r 6. EXEMPTION r 99. OTHER: <br /> r 9. STATE FUND 8 CO 622 <br /> CharkoneboxtobC cathch <br /> Legal ,,II <br /> btl Itl be T- IN(`dfTIIRFCC <br /> f t 0 IIb Sent to thekms/ leg Id b 9 yj�FCILITY <br /> b 2 erJc a 2 PROPERTY OWNER (- 3 TANK OWNER 423 <br /> DenIIICd110 <br /> can That Ne mf n pmwtlerl herein is II and accurate to the best of my knowkEge. <br /> SIGNAT RE I ANi <br /> DATE ,/, _ 624 PHONE 425 <br /> NAME OF AP �(ponst) d 0 �! 1? '// 74 <br /> QG ✓�� iw��2 625 TITLE OF APPLICANT �� �_,.,_� <br /> ivt L 27Z LLC77UE /%�c/i'� <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) aZ9 <br /> i <br />