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UNIFIED PROGRAMA CONSOLIDATED FORM <br /> j <br /> i <br /> TANKS <br /> j� UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per sire} <br /> /� �/� Page _ of _ <br /> TYPE OF ACTION r NEW SITE PERMIT tY,..RENEWAL PERMIT ..R S.CHANGE OF INFORMATCN rSxpryG+aMe- F� 7.PERMANENTLY CLOSED SrrE <br /> "[.,lets one Item only) 6 <br /> r 4 AMENDED PERMIT ocaf use anlY) d.TANK REMOVED 100 <br /> [ 5.'w'APCRARY SITE C.CSURE <br /> VM I. FACILITY 1 SITE INFORMATION <br /> a <br /> 3USIN E NAC0�M+y ;Same as AC:LJ7Y NAME or DBA-Oaing austness As.! 3 FAC:UTY'�©s <br /> E . todlLAJ <br /> NEATCROSSST EET 471 FACILaT'OWNERTYPE a, LOCAL AGENCY1p1S7RICT <br /> 5, COUNTY AGENCY' <br /> r I. :,CRPORATION I <br /> BUSINESS TYP GAS STATION r 3.FARM r 5.COMMERCIAL NOMOUAL t <br /> �// i '3. STATE AGENCY` <br /> r 2 DISTRIBUTOR r PROCESSOR r S.OTHER V s. ?ARTNERSHIP <br /> 7. r^EDERALAGENCY' <br /> 406 4oa <br /> TOTAL NUMBER OF TANKS "s factory on Inotan Reservation or 7f owner of UST s a folic agencc name cf%4wv,sdr of j <br /> REMAINING AT SITE msoands? afv,swn,sextan or arfx;e wnKn mermas no UST <br /> jh,s is the contaC xnon For the Lank remits) <br /> 404 r YNo 405 J06 i <br /> N. PROPERTY OWNER INFORMATION <br /> PROPERTY OWN11ER NAME 407 PHONE 40$ <br /> Ti'11 - I S�V11 vlJ` !Y C.4 f^LJ`�l� <br /> MAILING OR STREET ADDRESS 409 j <br /> CIT'( 410 STATE411 TIP CODE 412 _ <br /> S DCKIV rJ C- , C S�v s � <br /> PROPERTY OWNER TYPE [_ NOIVIOUAL I_ 4. LOCAL AGENCY f DISTRICT 5. STATE AGENCY 413 <br /> r1 CORPORATION PARTNERSHIP r3- COUNTYAGZNCY 7 <br /> FEDERAL AGcNCY <br /> III.TANK OWNER INFORMATION <br /> i <br /> TANK OWNER NAME414 I 'HONE 115 j <br /> DoT N� �6`06 �:NAILINGOR 5 EE T ADDRES15 j <br /> C:Tl 41 <br /> STATE 118 EP CODE 419 J / <br /> � <br /> 'ANK JWNERTYPE [ NONIDUAL r 4 LOCALAGENCYiDISTRICT 5, STATEAGENCY 420 <br /> r CORPORATION V PARTNERSHIP r S. COUNTY AGENCY 7. F_DERAL AGENCY <br /> 0 09901'Al IZALTION I IST STORAGE EEE ACCOI'KIT Ml WRER <br /> HQ 4 4 I # CaII(916)322-96669 if questions anse 4z1 <br /> i <br /> I <br /> INDICATE METHOO(S) j 1 SELF-NSURED r A. SURETY SOND 7_ STATE FUND r 10. LOCAL GOV=T MECHANISM � <br /> r <br /> Z. GUARANTEE r 5. +ETTER OF CREDIT I 3. STATE FUND 3 CFO LE I I ER I 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPT10N r 9. STATE FUND d CO 422 <br /> Checx one odx Id indicate wn+rX1 adorers.sr,ouxi be used fa Iagai notfioations Ano marling. — — Y' j,FACILITY 2 PROPERTY r]WNER r 3. TANK OWNER 123 <br /> I modal nctf'icatldns and l7i. s w 11 be sent•d the rani owner unless oox I or 2 as.necked. JP <br /> i <br /> i <br /> Candicauon: I caril y ihat the information orav+cad herrn is vve and accwate to[he best of my,knomecge. <br /> SIGVATUR A AN a �} i ]A1C424 I NE 425 <br /> J NAME 3F APPLd(7A (pnnt) x251 T rrL_r.,7PAPPLJCfNT 427 ' <br /> STATE UST FACILITY NUMBER i Far roeal use only) 1281 "=53 UPGRADE CERTIFICATE NUMBER(For.-Pear use Only) 429 I <br /> I <br />