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1. FIED PROGRAM CONSOLIDATED )RM C*C, o` <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY�31'py <br /> (one page per site) 1 <br /> Pay <br /> TYPE OF ACTION <br /> kL 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(SPecdl'aO 9e- r 7.PERMANENTLY CLOSED SITE <br /> (Cnecx ale dem only) r a.AMENDED PERMIT tical use only) r6.TANKREMOVEO 400 <br /> F S.TEMPORARY SITE CLOSURE <br /> '^ <br /> I. <br /> FACILITY I SITE INFORMATION <br /> GX 6winne Aa 3 FACILITY 100 <br /> BUSINESS NAME(Sarlle as FACIUTY NAME IX A-OokS G {y, � ja `£ <br /> J_vFACILITY OWNER TYPE r 4. LOCAL AGENCYIOISTRICT• <br /> NEAREST GROSSS WETd [ o <br /> G-A.MJt �TY�"_ n•-.. yet. CORPORATION r 5. COUNTYAGENCY• <br /> BUSINESS TYPE 1,GAS STATION r 1 FARM r 5.COMMERCIAL r 2- INDIVIDUAL r 6. STATE AGENCY* <br /> r 2 GIST STATION r PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is(xll an Iraun Resenau ar it caner at UST u a PUOIiC agency.name of avo I-r of <br /> REMAINING AT SITE lrus .? (Thi.i.an.M.m t=Person for Ne tarlklerewrai) <br /> q0a ryes XNo 405 406 <br /> It.PROPERTY OWNER INFORMATION q Q p Q <br /> �,.b viC� ALI.J ,fyl L PH OE / / / / /3 <br /> PROPERTY OWNER NAME 407 <br /> MAILING OR STREETgAD/DR11E,,SSp x409 J <br /> pL 6 VI 0 -1 oY - � TAi 411 ZIP 00 412 <br /> CITY 410 <br /> 14- cry„(, <br /> PROPERTY OWNER TYPE r 2 INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT - r 6. STATE AGENCY 413 <br /> ]yl1. CORPORATION r 3 PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III..TANK OWNER INFORMATION <br /> PHONE 415 <br /> TANK OWNER NAME 414 p p 4- p O N C <br /> MAILING OR STREET ADDRESS 416 <br /> STAT 418 ZIP C E 419 <br /> ITY 417 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r S. STATE AGENCY 420 <br /> r 1. CORPORATION r 3 PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> ,7 mIImRFp <br /> n2 <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise <br /> DICATE METHOD(5) 7. STATE FUND r 10. LOCAL GOVT MECHANISM <br /> IN <br /> r 1. SELF-INSURED r 4. SURETY BOND <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r e. STATE FUND&CFO LETTER r 99. OTHER <br /> r 3. INSURANCE r 6. EREMPTION r 9. STATE FUND&CD <br /> VI I <br /> Cnxk I E 1 hN atld MEe Mf legal R an0 �s+9 r 1 FACILITY r 2 PROPERTYOWNER r 3 TANKOWNER <br /> 1 RKd C 1 Il Dasentlometwk b 2 UfrheO <br /> CMITKauen: 1 rartM Nat Ne Ww I Wn pmo Kk Nw M,,oue and accurate to W.mg al my kn..I d9e. 424 PHONE IIII 9 4: <br /> DATE `� J 1 L3 - <br /> SIGNATURE OF APPLICANT <br /> NAME OF APPLICANT Wp ) I'n._11 O1 _ 1 426 TRLE OF PU T ppre"; 4. 27 <br /> T-'�v 428 1998 UPGRADE CERTIFICATE NUMBER-�(•ForNbml�wwoNY1 429 T� (7 <br /> STATE UST FACILITY NUMBER(ForkW ase aMi p Fp Q E n\\I,M <br /> 1 )[J2)Ia 11 1'y_ <br /> MAR 19 2004 <br /> ENVIE H <br /> WISERVICES <br /> P <br />