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UNIFIED PROGRAM CONSOLIDATED F <br /> II I <br /> l TANKS ] <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> lone page per site) <br /> Page <br /> ^yPS OF ACTION r I.NEW SITE PERMIT r }.RENEWAL PERMIT r 5.CHANGE OF INFORMATtCN ISP mange- r 7.PERMANENTLY CLOSED SITE <br /> 7Gheca we Item only) �/ <br /> qr a AMENDED PERMIT '�"m wMY1 A B.TANK REMOVED 77&OW 490017/�F5 r i.0APORARY SITE CLOSURE i / <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS (Same O� FACILITY NAME tyA-Dap a� 1FACIY:Oa I I. I ' <br /> ,NEARESTR9-r�,NEARESTST CROSS STREET I X 5�,L'/ � " LITAGILITY OWNER TYPE-75� r +. LOCAL AGENCYIDISTRICT• <br /> lf- I. CORPORATION r S. COUNTYAGENCY' <br /> BUSINESS TYPE [' 1.GAS STATION FARM r 5.c ;NOIVIOUAI" <br /> r 2 DISTRIBUTOR r 4 PROCESSOR r S.OTHER r 3. PARTNERSHIP r S. STATE AGENCY- <br /> 43 � r 7. FEDERALAGENCY- 402 <br /> TOTAL NUMBER OF TANKS 1.faeuty cm Irwon Rmer s.ar ^.f owtur of UST s a Doak agetxy name cr awernsar s <br /> REMAINING AT SITE ® vuse.aa? aiwswn,tecoon w bilre wnlm Doer..r UST. <br /> tThn is the funbc xfxn IM me UNt 2(ZfICi) <br /> a04 r Yee r Nb 405 408 <br /> II. PROPERTY OWNER INFORMATION <br /> PROTE OWNER NAME 407 PHONE apB <br /> F n <br /> MAILING OR STREET ADDRESS ^ a_O$O xt <br /> CIT. 410 V �L/11 '�-,'�,, J(�/�/f/ STA Eatt PCODE 412 <br /> c,q I �5ao <br /> PROPERTY OWNER TYPE2 :NOIVIOUAL r +. LCCALAGENCY 1 DISTRICT r i. STATE AGENCY ata <br /> r 1. CORPORATION [ }. PARTNERSHIP r S. COUNTY aGENCY r 7 FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 ?NONE 415 <br /> Sa,yne— 6t.4—)(}�w U-1 I <br /> MAILING OR STREET ADDRESS 6 <br /> IT> +17 I STATE is I AP CODE +19 <br /> TANK OWNER TYPE NOMDUAL C a. LOCAL AGENCY I OIS Ri IC r 5. STATEAGENCY A20 <br /> r I CORPORATION r 3. PARTNERSHIP r S. COUNTY AGENCY r 7. FEDERALAGENCY <br /> I <br /> c <br /> I (TK)HQ 4 4 I I I Call(916)322-9669 ifauestions arise +21 <br /> V PFTRrII FIIM IIGT FIND NY'Iel RFCO(1MCIRII ITV � <br /> INDICATE METHOD(S) r I. SELHNSURED r a SURETY BOND r 7. STATE UNO C 10. LOCALGOnV.TMECHANISM <br /> r 2. GUARANTEE r 5. TETTER OF CREorr r B. STATE FUNO b CFO LETTER 'X99. OTHER I1. 1 b'bi 0. <br /> F 3. INSURANCE r 6. r7(EMPTION r 9. STATE FUND d CD <br /> Cheat aneoox ro nbimte wninfl abwees snbun be uses tw Ieg.noteratwns ano maeix} r I. FACILITY 2 PROPERTY CWNER r 1 TANK OWNER a23 <br /> gh <br /> Y a met". <br /> Irl ":,d <br /> w 1 be sem•o ttM tank nwnx unbss Dox 1 cf ie mewteb. <br /> CanRwaWh,, I coney stat Me mlarmatam(eeMea heron a We are aCOYJte to the beet of MY kn W Ke. <br /> SIGNATURE OF APPLICANT ]ATE 424 ?HONE 425 <br /> NAME OF APPLICANT(pnn) 4261 TITLE OF APPLICANT 427 <br /> I <br /> STATE UST�FACILITY NUMBER(Fw: use amyl 4291 •Sa UPGRADE CERY.F+GTE NUMBER)Fc,oa ere onlYl '29 <br /> Peu� e, a-" 3 - 8-p 1 <br /> �7 'a `)da 4-M 0f <br />