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c0 PROGRAM CONSOLIDATE M II <br /> TANKS <br /> UNDERGROUND STORAGE TANKS — FACILITY D6site) <br /> C . C RENEWAL PERMIT C 5,CHANGE OF INFORMATION/SPCemrYaMW0- 7.PERMPNENTLY CLOSED SI <br /> TYPE OF ACTION 1NEW SITE PERMIT ]. C S.TANK REMOVED 400 <br /> IClxs ono Item only) �oca0 mpORAR YI J�EaQ OO `� <br /> C d.AMENDED PERMIT <br /> [' 6 TEMPORMYSITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION <br /> FACUTY m s <br /> 3USINESS NAME(Same as FACILITY NAME a OBA-Oonq Blwwss A91 ] d <br /> ( 1 FACILITYO ER TYPE C a. LOCALAGENCYIOISTRICT' <br /> NEAREST CROSS STREET .a01' C C a C 1. C.')RPORATION r S. COUNTYAGENCY* <br /> (�• F IA/ INOMDIKL C 6. STATEAGENCY, <br /> 3USINE STYPE GAS S ATION C ].FARM C 5.COMMERCIAL C ] PARTNERSHIP C 7. FEDERAL.AGENCY' .2 <br /> C 2 DISTRIBUTOR C 4,PROCESSOR C 6.O HFR <br /> 43 'If l v w of UST s a aAlaaa9erlP!name ct suoervna of <br /> TOTAL NUMBER OF TANKS Is faa11N on I(Ipmrt ReservmlPn u bmssm seNarl br dow� aCaretM;IIs UST. <br /> REMAINING AT SITE U1tawwwds7 (Tlnsm Ute cornea oarsbn fbr Uls tank remr'bs) <br /> 404 <br /> 3 C Yee 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PHO—NTE 409 ^ <br /> PROPERTY ,\ER NAME 407 t O 'e p(O ^O(g6—ID <br /> MAILING OR STRF ADDRESS 409 11 <br /> STATE „a11 ZIP CO E +12 <br /> CITY _a1D IDISTRICT/ <br /> PROPERTY OWNER TYPE K• I�L/�>•�L/ INOMOUAL C a. LOCAL AGENCY 101STR1CT C J. STATE AGENCY +17 <br /> C 1. CORPORATION ( }, PARTNERSHIP C S COUNTY AGENCY C 7 FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> ?HONE 415 <br /> TANK OWNER NAME 414 <br /> S <br /> MAILING OR STREET ADDRESS 416 <br /> ATE 416 LP CODE 419 <br /> 417 <br /> C 4 LO CAL AGENCY I DISTRICT C 6. STATEAGENCY 420 <br /> TANK OWNER TYPE INDMOUAL C 7. FEDERALAGENCY <br /> C I CORPORATION [ y PARTNERSHIP C S. COUNTYAGENCY <br /> a21 <br /> TY TK)HO 4 4 <br /> Call(916)322-9669 if questions arise <br /> INDICATE METHOO(S) C T. $ELF-INSURED C n. SURETY BOND <br /> C 1 STATEFUND C 10. LOCALGOV-TMECHANISM <br /> . STATE FUND S CFO LETTER C 99. OTHER:- 4 <br /> C 3. GUARANTEE C 5 I LETTER Of CREDIT C 9 STATE FUND d CD <br /> C ]. INSURANCE C 8 EXEMPTION <br /> I I Ff`Ai 423 <br /> T' J' 7 PROPERTYOWNER C 1 TANK OWNER <br /> Ct1ecK b e w o- Mab be sob e1'kM <br /> f 0 1 I h mr <br /> V]( AP121 ICAW7 Sl <br /> CenA�atlan: certKY Ihel Ns rcUormasbn Prb'/'GBtl Waren is we ane ararete w the best of mY Nwa'so9s- <br /> DATE 424 PHONE 425 <br /> SIGNATURE OF APPLICANT <br /> x261 a27 <br /> NAME OF APPLICANT(Pnnrl TRLEOF APPLICANT <br /> 42Bi 95BUPGRADECERTIFICATE NUMBER IFo/bcal uSe onM a29 <br /> STATE UST FACILITY NUMB/ER(For%Veal use amyl <br /> G� �yLCG q .0 -0 1 <br /> l � r• <br />