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IED PROGRAM CONSOLIOATEM <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS <br /> !'Ile <br /> zage ce,,5.;�) i <br /> 'iPE OF ACTION 0<, Ne,SIT.-Ps;wrr 3-RENEWAL PERMIT S.C�AvGE OF lNORM ;CN Saen <br /> se ' Pare — 't <br /> IC.'ecwe item only) . RNENTLY <br /> c�.,s=_�sIT, <br /> 4 AMEN0E0 P=_R.%1IT ccar use only) F' d.TANK REMOVED 100 <br /> C 5.T;!dPCRARY sr;E CLOSURE <br /> I.FACILITY l SITE INFORMATION <br /> 3US;NESS NAME(Same as FACILITY NAME er CBA.Qa09 4USMeSS Aa) 3 FAC!U r:'0 s <br /> 14 1W 14 FAST 6-AS f lFA- GCC (3� 3 I � � I I I I , <br /> 6 NEAREST CROSS STREET y% 1pt =AC:LIT`.'OWNER TYPE t. C^RP ORATION r 't. LOCAL dG'cNCY1Cl5'R:C'. <br /> 3U54NES5 TYPE i''jy'.GAS STATION r 3.FARM r 1Xz -NCNIOUAL r 5 s-.r. ArE r airy Y' <br /> i.CZ'MMIsRCtAL [� 5. STATE AGENCY- <br /> 2.OISTMBUTCA 4..PROCESSOR d.OBER r 3. ?ARTNERSHIP I r T. FEGERALAG'cNCY' 4C2 <br /> TOTAL.NUMBER OF TANKS :s'acltry on Inc=Resereawn or ^!-.ner or UST-s a"Uol-c agercr.name cr sucervuar at <br /> ets <br /> REMAINING AT SITE Tusu ? =.t3 an.se=n cc a:re wrlim ooerwas;re USS. <br /> 1G4 (Tins o me mnta=Gerson for me Tarot recr=) <br /> r Yea 4C5 4C6 <br /> H.PROPERTY OWNE=R INFORMAMN <br /> PROPERTY OWNER NAME 397 <br /> 41 0 0 4( t. fY 4 Id Y G p/ '�� ���� ` ������ PHONE <br /> MAILING OR STREET AOORESS 9 L,4N <br /> 2 3�i~� lfrTl'2�L} i A� <br /> CiTY 414] <br /> I STATc at r � ZIP C00.- 412 <br /> j _(: <br /> . 0 lL TUI`) frf� C�J G 0 <br /> PRGPERTY OWNER TYPE - .NOIVIOUAL 1. '_OCALAGE.`lCYfOtS-.R:CT 3, STA..AGENCY 113 <br /> r :. CORPORATION <br /> I� 3. PARTNERSHIP i. CoUNTYAGE.NCY [ 7 =EOERALAGENC.' <br /> III. TANK OWNER INFORMATION <br /> ANK OWNER NAME 114 P40NE 315 <br /> MAIL;.14'U OR STREET AOORESS +tfi <br /> 417 STATE :a TIP C00- 419 <br /> 5 �cc j 7�' C/� /s--905 <br /> i TANK OWNER rYPG INONIOUAL 3. !_OCAL AGENCY l0R5-lr ICT [' <br /> C F CORPORATION i. STAicAGc4CY 12(7 <br /> C 3. PARTNERSHIP 5. COUNTY AGENCY r FE7ERALAGeNCY <br /> I <br /> I fi TK)HQ 4 a Cali(916)322-9509 if questions arise 12, <br /> ,r acrvnr =TIM USTETUA C16; RESP_ONSIRI' lly _ <br /> tNOICATE METHODS) (' I. SELF-INSURED r 4. SURETY BOND CA STATE FUND r 10. LOCAL GOVsT oMECHANIS.1,I <br /> r 2. GUARANTrE r 5. '--TTFR OF CRE01T r 3. STATE FUND S CFO L---.T---R 39. OTHEAL- _ <br /> 3 <br /> f 3. INSURANCE T S. Ex.-FAPT1gN r 3. STATE FUNDS OD <br /> C.'+aa one box to ncicate wmcn adcress mvul4 oe used fee'""nouAvttons ana maven¢ [� •. FACILITY / PROPERT`.'OWNER r 3" YANK O'hNcR '�- <br /> t_ al rauflcattons and Mailings will be virl! M1!3 f C+�N!r untess tax t ce 1 Is Cr'" C. <br /> i <br /> o <br /> Cer.d�natton: I coney mat the ntKnalicri crw o en H true arro a=urwa la lite Oast el my knaw+eoca <br /> SIGNATURE OF APPLICANT L L+/" 7A GJ /ZL, / L; •z 124 I ?HON �Gt17 6 ) �,� .� 125 <br /> NAME OF APPLICANT(prrrt>pp 4254{ TiT1.E q APPLICANT 1/ J 1271 <br /> L-UU rY4D� C1�Cr�YE'N I [�iJ�`t�'�f� <br /> ST.;T.-UST FACILITY NUMBER frar;ool use or.ry) 4291 '�- a UPGRADE CERTIFICATE NUMBER fFer,ocar,se only) 429 <br />