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UNIFIED PROGRAM CONSOLIDATEO FORM <br />UNDERGROUND STORAGE TANKS - FACILITY <br />TYPE OF ACTION r I_ NEW SITE PERMIT r 3. RENEWAL PERMIT r S CHANGE OF INFORMATION IS <br />(CAxeoro item omy) aeory Marga <br />r a. AMENDED PERMIT ;ora'.se ardT) <br />r 6 TEMPORARY SITE CLOSURE <br />TANKS <br />lone page per Ste) <br />Paye — x _ <br />r 7 PERMANENTLYCLOSEO SITE <br />r S TANK REMOVED 4DD <br />I. FACILITY I SITE INFORMATION <br />BUSINESS NAME (Same a9 FACILITY NAME r OBA- O/o�sg BuN�nA-AVs A91 3 <br />FACILITY 10 a <br />SIGNATURE OF APPLICANT <br />DATE O / r / • 0 424 <br />PHONE $r ? 425 <br />/ T 6 <br />NAME OF APPLICANT !Poor) n Dy��y �C 426 <br />fC D <br />TITLE OF APPLICANT a27 <br />{�JdYh�'>��• <br />��iQ 1�Jpc►Hi yNeOa!F=1 <br />NEAREST CROSS STREE67 401 <br />6 ',it <br />FACILITY OWNER TYPE <br />r a. LOCAL AGENCYro1STRICr <br />Y <br />r � <br />r INOMOUAL r S. COUNTY AGENCY' <br />BUSINESS TPE F GAS STATION r 3. FARM r 5. COMMERCIAL <br />r Z. DISTRIBUTOR r a. PROCESSOR r e. OTHER <br />r B. STATE AGENCY' <br />r PMTNERSHIP <br />403 <br />r 7 FEDERAL AGENCY- 402 <br />TOTAL NUMBER OF TANKS <br />REMAINING AT SITE <br />Is fiIi w mzal Re9aYemn a 'ITO of UST's A oNOIc agaky nano a 9ueervrsa a <br />O I <br />mutlAnna? oNvcn. s4990r1 a aNce wnKn oosrvee x,e UST <br />iT11M if els Wr11C aer9on fa Yts faN tamrES1 <br />404 <br />ryes r NA 405 405 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408 <br />LOC L� �Oz1AT1fJ <br />`i3� 067 <br />IMILING OR STREET AOORESS 409 <br />(:R8 I N Are ►r7h �D . <br />CI 410 <br />STbCt-raN STAan <br />CA-q� <br />., <br />s Is <br />PROPERTY OVMER TYPE r 2 'NDMOUK r a. LOCAL AGENCY 1 DISTRICT r i STATE AGENCY a13 <br />r <br />1. CORPORATION r 1 PARTNERSHIP r S. COUNTYAGENCY r 7 FEDERALAGE4CY <br />Ill. TANK OWNER INFORMATION <br />TANK OVMER NAME ala <br />s•4¢rne -A-s Peovla2l�d OANel. <br />PHONE a15 <br />MAILING OR STREET ADDRESS a16 <br />417 <br />w 419 LP CODE :19 <br />TANK OWNER TYPE r 2 iNDMOUAL r a. LOCAL AGENCY I DISTRICT I'S STATEAGENCY a20 <br />r <br />1 CORPORATION [ 3. PARTNERSHIP r 5. COUNTYAGENCY r T FEDERALAGENCY <br />TY (TK) HO 4 4 1 - 1Da 1148104 <br />Call (916) 322-9669 if questions anse 421 <br />INDICATE METHOD(S) r 1. SELF-INSURED F4 SURETY BOND r 7. STATE FUND r la LOCAL GOVT MECHANISM <br />r 2. GUARANTEE r 5. LETTER OF CREDIT r 9. STATE FUND S CFO LETTER r 99.OTHEF. <br />r 3. INSURANCE r S. EXEMPTION r 9. STATE FUND a CO a32 <br />Cileal oro bas 10 ngiola wnM adbese N,oOM Ite used fa byN nobficiti and minct, r I. FACILITY r _ IROPFRTY OWNER r 3. TANK O MER 423 <br />._80a1 nddlCdlbns arM metlVlns.1116e z 10 Me arll!OW11M lNIB9900Zt a.�.sTBJIsO <br />Da,ti,:AOn: IC dy 11191 UM Tlalnaeen naM19 And aWaW 10" M91 of m k..*0gs. <br />SIGNATURE OF APPLICANT <br />DATE O / r / • 0 424 <br />PHONE $r ? 425 <br />/ T 6 <br />NAME OF APPLICANT !Poor) n Dy��y �C 426 <br />fC D <br />TITLE OF APPLICANT a27 <br />{�JdYh�'>��• <br />