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U -" FIEO PROGRAM CONSOLIOATEO F-')RM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACtUTY <br /> (ane PB4e Per site) <br /> i <br /> }y <br /> TYPE OF ACTION r I,NEW$ITE PERMIT r 3.RENEWAL PERMIT ,,KS.CHANGE OF MFORMATICN ISP ryry ge- r 1.PERMANENTLY CLOSED SITE <br /> (G1xx ane item oy) o al use oM,) r 8.TANK REMOVED <br /> [- a AMENDED PERMIT T, , <br /> 'E!APORARY$rtE CLOSURE <br /> -/� I.FACILITY I SITE INFORMATION Re-C' ,_� (a 31?51! 4 <br /> iI <br /> BU��` IINESS NAM aqtob `m/'a.�a's,FACIUI ,NAME a DIBA-OPI BUalMaa Asl 3 �A^ F©O'� D� <br /> NEAREST CROSS STREET �1 L0ctbUl/O 1'll'L(-Tal/Ki V,x. FACAI OYMEER TWE r s. LOCAL AGENCYl01STRICT- <br /> T �� U{q--'�_,CDRPORATION r S COUNTY,AGENCY' <br /> BUSINESS TYPE t.GAS STATION r 3.FARM r 5.COMMERCIAL ` a. INOMOUAL r s. STATE AGENCY- <br /> r 2 DISTRIBUTOR r PROCESSOR r 6 OTHER r 3 PARTNERSHIP r T. FEDERALAGENCY• 402 <br /> aO3 <br /> TOTAL NUMBER OF TANKS 'a faawy on mown Reawvetlon w 'II owrwr[f UST-.z a aIce agercY:ume ct suo <br /> REMAINING AT SITE xusearinz? orvlsKm,semen ar ofM1ra wnlT ooewtss'^e UST. <br /> (Th�s.s oIe�xrsan far UIa ren remaa I <br /> 404 r Yea 405 46 <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408, <br /> MAIUNG OR STREET DRESS +Oa <br /> Q• X [ at <br /> CI 410 ITA an E <br /> I c�- � <br /> PROPERTY OWNER TYPE���,,,---...��/ r Z. NOIVIDUAL r +. LOULAG'cNCYIDISTRIC• r 5. STATEAGENCY a13 <br /> JU 1. CORPORATION [- y PARTNERSHIP r i_ COUNTY AGENCY r T. FEOEFL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 _ PHONE <br /> bq 79y a7aal <br /> ANIL' GOR STREET ADD SS +16 <br /> CIT- dr <br /> ♦ slI S AaJ4^1�8 319 <br /> J <br /> TANK 01 TYPE �� r 2 INDIVIDUAL C 4. LOCALAGENCYIDISTRICT r S. STATEAGENCY IMIJt. CORPORATION r 3_ PARTNERSHIP r 5. COUNTYAGENCY r T. FEDERALAGENCY <br /> TY(TK)HO 4 4 - Q Call(916)322-9669 if questions arse 421 <br /> e <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r T. STATE FUND r 10. LOCALGOWTMECNANIMA <br /> r 2 GUARANTEE r 5. LETTER OF CREDIT �STATE FUND&CFO LETTER r 99. 07/1ER <br /> r.t <br /> r 3. INSURANCE r S. EMPTION r 9. STATE FUND d CD a22 <br /> G'+ecx Dna Dox:o molcate wmrn aeoreae ztM)uIe I»uaea fa <br /> 49M rx)I4NJIIpIs Arlo ma4iip. r !. FACILITY r 2 PROPERTY OWNER TANK OWNER 423 <br /> rt � <br /> VII MIT qIrmA7`I IRF <br /> CanlrwallPn. I cw*Vat I"infolmalwn or 4v nxen,s I"aM a W w IM Dart Pt mY xnowleage. <br /> SIGNATURE OF APPLICANT I DATE 424 PHONE 425 <br /> NAME OF APPLICANT(P W) 42SI TITLE OF APPUCANT 127 <br /> STATE UST FACILITY NUMBER(For.ncal use omYl +281 '9F5 UPGRADE CERTIFICATE NUMBER(F;*f uw Deny) 429 <br /> a3 <br /> 1252 <br />