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13 r fig ter TT <br /> =UNDERGROUND <br /> NIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> STORAGE TANKS — FACILITY <br /> (one page per site) <br /> �// Pays _ of _ <br /> TYPE OF ACTION ( ,NEW SITE PERMIT r 3.RENEWAL PERMIT . C 5.CHANGE OF INFORMATION(SPecifIrOaNis- I- 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) - \ 9,AMENDED PERMIT AD, use onty) r S.TANK REMOVED 400 <br /> I <br /> I'6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME Same es FACILITY NAME ar 0� Su�ss As) FACILITY l0 a <br /> .v�7 L 6 A t <br /> NEARESTC STREET 401 FACILITYOWr 4. LOCAL AGENCYIDISTRICT' <br /> �t D C 1. CORPORAr 5. COUNTY AGENCY' <br /> BUSINESS TYPE GAS STATION Ir 3.FARM IS.COMMERCIAL INDMOUAr S. STATE AGENCY' <br /> 2.DISTRIBUTOR T a PROCESSOR r 6.OTHER T 3. PARTNERr 7. FEDERALAGENCY' 902' <br /> 403 <br /> TOTAL NUMBER OF TANKS Is faality,im Indan Reservation or M owner P1 UST is a Pwx agency:name of wPe,,wr of <br /> REMAINING AT SITE usuOarWs9 �Ths y'me�q Person for M Iarvt recoras)jT <br /> 404 rYea X.- ADS 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 90e <br /> GOLLL Z <br /> MAILING OR STREET AOD Ss <br /> 911 ZIPCODE <br /> CITY S 410 <br /> PROPERTY OWNERTYPEcpor-INDNIDUAL I- 4. LOCAL AGENCY I DISTRICT C 6. STATEAGENCY 413 <br /> I 1. CORPORATION I'g_ PARTNERSHIP C 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 419O PH NE: 315 <br /> !/ c z_�J•t/'/^D 3 / 3570 <br /> MAILING OR STREET ADDRESS- 41 l) <br /> CI n] S CC• (fJ ATE 418 21P OD 319 <br /> G'57 In 5 S <br /> TANK OWNER TYPE pNIDUAI C 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> I 1. CORPORATION r 3, PARTNERSHIP C S. COUNTYAGENCY I 7. FEDERALAGENCY <br /> TY(TK)HO I 4 - Call(916).322.9669 if questions arise 421 <br /> INDICATE METHOO(S) P 1. SELF-INSURED r 4. SURETY BOND T 7. STATE FUND T 10. LOCAL GOVT MECHANISM <br /> I' 2. GUARANTEE C 5. LETTER OF CREDIT r a. STATE FUND 6 CFO LETTER r 99. OTHER:-422 <br /> NSURANCE r a. EXEMPTION r 9. STATE FUND 8 CD <br /> Cheri ons Dox to inEiwe whiUt aeereaa shwa Oe uaee/or legal rel9lwuons and maJkg r I. FACILITY ROPERTY OWNER r 3. TANK OWNER 423 <br /> I of 81i n marlin will Pe aMt me lank own nleea z,or <br /> N M. <br /> Ce,ori I minty mat the mdormatkm PrM dmf herein is We ane araaate to 6e test of my knoebags. <br /> SIG RE F PU PAT/O-Q PHONF �� �70 425 <br /> NAME gFO UJ(➢nnl 926 TITLc/ OF�PP /CANT 427 <br /> STATE UST FACILITY NUMBER(Foriocal use orgy) 428 199a UPGRADE CERTIFICATE NUMBER(kr local use PnlYl 429 <br />