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UIEO PROGRAM CONSOLIDATED II <br /> u j <br /> 8/zl/nag TANKS <br /> UNDERGROUND STORAGE TANKS — FACILITY ' <br /> Ids wla3ivq onePagePersrtel <br /> Page <br /> TYPE OF ACTION r t.NEW SITE PERMIT r• 1.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Soeary blame- r 7.PERMANENTLY CLOSED SITE <br /> (Ctlxx ona dem only) r 4.AMENDED PERMIT aniy) r6.TANK REMOVED 400 <br /> r5. EMPORARY SITE CLOSURE <br /> I o D I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Sam.as FACILITY NAME <br /> m OBA-DOmg dusness ) 1 FACILITY 10 A <br /> It)QW 4 �� 0 <br /> NEAREST CROSS STREET p t/- `FACJ UTY OWNER TYPE r 4. LOCAL AGENCY/DLSTRICT• <br /> ��j[`t. CORPORATION [� i. COUNTY AGENCY' <br /> BUSINESS TYPE 1.GAS STATION T 3.FARM r 5.COMMERCIAL 1 2 ;NOMDUAL (-9. STATE AGENCY' <br /> r 2 DISTRIBUTOR r 4.PROCESSOR IF S.OTHER r 3- PARTNERSHIP C t. FEDERAL AGENCY- a02 <br /> 403 <br /> TOTAL,NUMBER OF TANKS 13 faalay w lMun Reswvalw a if Mea Ucy.nam. xp <br /> LIST s"Is:agenne d Mw of <br /> REMAINING AT SITE maidands7 y 15mn,+e Won w 0ifce wnitllaMnvas me UST. <br /> (This I5"aalda asset for ele Irx reWlas) <br /> 404 [•Yea 40.5 406 <br /> It. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNERNAME 407 PHONE I <br /> TharF c� srPz �ta3 -9&7 <br /> MAILING OR STREET ADDRESS +09 V ,^^^ I <br /> CITY 410 STAOtt CODE n12 <br /> • aS200- <br /> PROPERTY OWNER TYP �� F 2 'NOIVIDUAL C a. LOCAL AGENCY I OISTRICT C 5. STATE AGENCY 413 <br /> 1)(1. CORPORATION r' 3. PARTNERSHIP C s. COUNTY AGENCY T 7 FEDFRALAGFNCY <br /> 1� III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 ? NE 15Act <br /> '• E It /1 U <br /> MAILING OR STREET DORESS +t6 � � i <br /> 417 STATE +18 ZIP CODE 419 <br /> 11) e 1 <br /> TANK OWNER TYPE C Z. 'INDIVIDUAL C- 4. LOCAL AGENCY/DISTRIC• T 5. STATE AGENCY 420 <br /> 1. CORPORATION r 3. PARTNERSHIP C 5. COUNTY AGENCY C 7. FEDERAL AGENCY <br /> X, C <br /> 'I _ <br /> nl'AlTY(TK)HO 4 4 10161M,14 <br /> Q d/ i Call(916)322-9669 if Questions apse 421 <br /> ��911 all <br /> INDICATE METHOD(S) T SELF-INSURED L 4, SURETY BOND C 7. STATE FUND r -0. !OCAL GOVT MECHANISM <br /> r 2 GUARANTEE r 5. LITER OF CREDIT r a. STATE FUND S CFO LETTER r 99. OTHER <br /> r 1. INSURANCE r 5. EXEMPTION I.9. STATE FUND d CO 42 <br /> i <br /> Cheri one eek to measle wnem addess moue W used W"al Ml f abOns aml ma6lwM- r 1. FACILITY r• L PROPERTY OWNER TANK OWNER 423 <br /> If t no 1 Ilb M m Mt eoa 1 Or 2 1,WaMa(l, <br /> Cw&,.IWn: I cents mat me idonnalan-10NO g harem n eue and acarine to the east d MY kroWNdge. <br /> SIGNATURE OF A ICA I DATE 424P NE 1225 <br /> NAME OF APPLICAN p n 426 TITLE 01 APP NT 427 <br /> u PZdam <br /> STATE UST FACILITY NUMBER(Fo I=sf use Only) 4281 '998 UPGRADE CERTIFICATE NUMBER(Farl=sl use only/ 429 <br />