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D PROGRAMMIMS D <br /> OLIDATEFO <br /> UNDERGROUND STORAGE TANKS - FACILITY Page <br /> of .Z <br /> (One page per site) <br /> ' <br /> 7 PERMANENTLY CLOSED SITE 400. <br /> [3 3.RENEWAL PERMIT <br /> [35.CHANGE OF INFORMATION ❑8.TANK REMOVED <br /> TYPE OF ACTION 1.NEW PERMIT 13 <br /> ❑4.AMENDED PERMIT (Specify change) <br /> (Check one item only) ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE MORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Bon-en'As) 3. FACILITY D D <br /> ID i <br /> T V 44+-�'I• Ly'�' 401 FACILITY OWNER TYPE Ll 4.IACAL AGENCY/DISTRICT• ° <br /> NEAREST CROSS STREET 91.CORPORATION ❑5.COUNTY AGENCY* <br /> -o. 4- kAy�AA Rte- d02. 2.INDIVIDUAL ❑6.STATE AGENCY" <br /> 5.COMMERCIAL O 3 PARTNERSHIP ❑7.FEDERAL AGENCY" <br /> BUSINESS 1.GAS STATION ❑3.FARM ❑ 6 OTHER 406. <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ <br /> 404. Is facility 0n Indian Reservation 405. •If owner of UST is a public agency: nacre o[supervisor of division,section or <br /> TOTAL NUMBER OF TANKS office which operates the UST. (This is the contact person for the tank records.) <br /> or trust lands? <br /> REMAINING AT SITE (3 Yes 1yNo <br /> II. PROPERTY OWNER INFORMATION 40A <br /> PHONE <br /> PROPERTY OWNER NAME "7o7- <br /> MAILING <br /> 07"MAILING OR STREET ADDRESS `>�� 412 <br /> n.�TTonl �- 410. STATE 411. Zip CODE <br /> 1TY a^I ' 4GA 6•74oI <br /> CITY au. <br /> 6 7A 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> PROPERTY OWNER TYPE 1.CORPORATION ❑3 ❑5.COUNTY AGENCY ❑7-FEDERAL AGENCY <br /> .PARTNERSHIP <br /> III. TANK OWNER INFORMATION 415 <br /> 414, PHONE <br /> TANKOWNERNAME 70-7 `J( o 1321 416. <br /> ^ pew L-AA <br /> MAILING ORT ET�AD`jDRESS Gj-1L419 <br /> 417 STATE a1s. ZIP CODE <br /> GA �"�Zk <br /> CITY U� <br /> 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 4zo. <br /> TANK OWNER TYPE 7.FEDERAL AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ <br /> IN. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 4 <br /> Call 916 322-9669 if uesrions arise <br /> Ty TK H 44- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY lo. GOVTMECHANISM <br /> INDICATEMETHOD(s) [11.SELF-INSURED C]4.SURETY BOND 7.STATE FUND 99,OTHER: <br /> ❑2.GUARANTEE [36.LEXOf ION CREDIT ❑9.STATE STATE FFUND&CD LETTER <br /> ❑3.INSURANCE ❑ EMP <br /> VI. LEGAL NOTIFICATION AND <br /> MAILING ADDRESS <br /> Check one boa to indicate which addRae.kould be aced fot legal BOtlfleadons and mailing' <br /> (�3.TANK OWNER <br /> Legal notifications and mailings will be sent to them owner uolcss bon l Or 2 u checked. ❑ 1.FACILITY [12. PROPERTY OWNER <br /> VII. APPLICANT SIGNATURE <br /> ---7707.- <br /> za. PHONE <br /> Certlficadon: certify that the inforrnation provided herein is true and accurate a the best of my DATE <br /> SIGNA OF PL NT _ r-� 707- 7&5-1GI <br /> 426. T LE OF APPLICANT c� <br /> NAME F APPLICANT(prinqt) O t S �-T <br /> `d: , [z �A�f� 423. 199911 37 CERTIFICATE NUMBER(Agency ase only) <br /> STATE UST FACILITY NUMBER(Age Y are only) <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-e(1/99)-1/2 <br /> http://wwv.unidocs.org <br />