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UNIFIED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS <br /> TYPEOFACTION (One pgge per rile) <br /> (Checkw owr,my) r 1.NEWSITE PERMIT r 3.RENEWAL PERMIT <br /> S.CHMGE OF INFORMATION(SpeO7y _ � - d <br /> r 4.AMENDED PERMIT brel useONy) y L-S Lt F 7'PERMANENTLYCLOSED SITE <br /> r 6.TEMPORARY SITECLOSURE r8_TANK REMOVED IM <br /> BUSINESS NAME(Same as FACILITY NAME w DBA-Oa'ng As) 3 <br /> LFACILITY/SITE INFORMATION <br /> Business <br /> FACILITY ID k <br /> N EST CROSS STREET <br /> 401 <br /> FACILITYOWNER TYPE <br /> BUSINESS TYPE rO�_-. F 1.CORPORATION r a.'O AGENCWDJSTRICT- <br /> (�STATION r 3.FARM F 5.COMMERCIAL r(DINUMDUAL <br /> r 2.DISTRIBUTOR F 4.PROCESSOR r 1-5.COUNTY AGENCY• <br /> 6.OTHER r 3.PARTNERSHIP r 6.STATE AGENCY• <br /> TOTAL NUMBER OF TANKS 403 <br /> REMAININGATSITE Ishal4yon lrMian Resarvaaonw F 7.FEDERALAGENCY• 4@ <br /> 3 Wsaa Os7 manner a Uwe pmw,,e rynameasupe wa <br /> 41M F (Thmis sectionwa6cewlnai aPemtss be UST. <br /> F Yes P-NO 405 (Th' be cwlad person M the tank mm .) <br /> PROPEI RTY OWNER NAME 407 11.PROPERTY OWNER INFORMATION <br /> hf <br /> MAILING OR S)yT�RE DRESS 4pg T IT?!V PHONE 408 <br /> CITY 41D �- 0 <br /> PROPE OWNER TYPE STATE 411 ZIPCODE 412 <br /> rrryyy <br /> r 1. CORPORATIONy 2. INDIVIDUAL F 4. LOCALAGENCY/DISTRICT <br /> ,r 3. PARTNERSHIP F 5.COUNTYAGENCY r 6.STATEAGENCY 413 <br /> F 7. FEDERALAGENCV <br /> TANK OWNER NAME ala III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> MAILING OR STREETADDRESS 416 <br /> CITY 417 <br /> STATE 41a ZIPCODE 419 <br /> TANK OWNER TYPE <br /> F 1. CORPORATION INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT <br /> r 3. PARTNERSHIP r 6.STATE AGENCY <br /> 420 <br /> F 5. COUNTYAGENCY <br /> r 7. FEDERALAGENCV <br /> TY(TK)HO 4 4 - Q 3 <br /> a f{ Call(916)322- <br /> 9669 if questions arise <br /> az1 <br /> INDICATE METHODS) ,1 SELF-INSUREO r4.SUREfYBOND <br /> r 2. GUARANTEE r 5.LETTEROFCREDITR7. STATE FUND r 10. LOCAL(�V=TMECHAMSM <br /> r 3. INSURANCE r 8. STATE FUND B CFO LETTER j 89 OTHER <br /> r 6.EXEMP ION r 9. STATE FUND 8 CD <br /> 422 <br /> Ghear ane Ear b eNlrale which aawess shotty Ee useCbrlegal aatracalions arM maiFng. <br /> 1.FACILITY r 2. PROPERNOWNER F 3 TANK OWNER 423 <br /> CetEfiwEm:I ceNy bat be irtlwrtytron p;a,•gee haven is true an0 amrtale to Ne hest amy knwNetlge, <br /> SIGNATURE OFAPPLIC <br /> DATEq <br /> NAM OF APPLICANT n NQy. 0 ��• �� � 425 <br /> 426 TITLE OFAPPLI 427 <br /> STATE UST FACILITY NUMBER(Fxbcal use only) <br /> n 428 1998 UPGRADE CERTIFICATE NUMBER(Fwbcel uss oMy) 429 <br /> �ece� Je�x dJ defy <br /> I IP(:F(I tqq <br /> yY>:� S FnrmrnHv CWR(.R Fnrm A <br />