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06/07/2001 13: 16 2094683,0FIFTH FLOOR PAGE 02 <br /> UN(rITEII PROGRAM CONSOLIDATED F - <br /> 40 17 ,V <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per s+re) <br /> Pap - of <br /> TYPE;OF ACTION /1 NEW SITE PERMIT r 3,RENEWAL PERMIT I' 5.CHANGE OF INFORMATION(S,ceary change- r 7.PERMANENTLY CLOSEO SITE <br /> (Chick one(fern only) 4.AMENDED PERMIT tical use only) _ r 8.TANK REMOVED 400 <br /> r <br /> n r 5,TEMPORARY SITE CLOSURE <br /> '4.[�l NA R LTi}�`� `-`/ I.FACILITY J SITE INFORMATION <br /> BUSWESS NAME(Same as FACILITY NAME of DBA-Doing Business As) 3 FACILITY ID A <br /> NEAREST CROSS STREET 40T FACILITY OWNER TYPE [' 4. LOCALAGENCY/DISTRICT' <br /> rK,. CORPORATIONCORPORATIONoN <br /> ' r 5. COUNTY AGENCY' <br /> OU51NESS TYPE j„<j_GAS STATION r 3,FARM I- 5.COMMERCIAL r 2, INDMDUAL r 6. STATE AGENCY- <br /> 2.OISTRIBUTOR <br /> GENCY- <br /> 2.OISTRIBUTOR r4,PROCESSOR r 6.OTHER •3. PARTNERSHIP <br /> � 7. FEDERAL AGENCY• eat <br /> 403 <br /> TOTAL NUMBER OF TANKS le faacty on lnon Reservation of 'If a Tw of UST is a owls ogere-y name Of:UPc ser Of <br /> REMAINING AT SITE vusaands7 division,-.Cion or oMloo u n%ch operattrs the UST. <br /> (This i1 the cw"a Person for the taro[remroa.) <br /> 4De + <br /> Yes r No ao5 a06 <br /> � iI,(,I ✓r,'((.v(i.� 1 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> P'l I)N 11 I_ (7 o,I->MAr;1 1 La P hf �TL.� G <br /> IIfNG OR STREET AOORESS 409 <br /> TTY 410 S A E 411 IP COD 41 <br /> PROPERTY OWNER TYPE (- 2. INDIVIDUAL r 4, LOCAL.AC,;-!NCY/DISTRICT r 6. STATE AGENCY 411. <br /> I 1. CORPORATION R 3 PARTNERSHIP r 5, COUNT Y AGENCY I 7, FEDERAL AGENCY <br /> 1� III_TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 416 <br /> ._)�, -\ f(,(?1) LL , I, ,�. 'rvC� � �7- <br /> MAILING OR STREET ADDRESS 416 <br /> CITY J17 5 A 410 <br /> IP CODE s1 <br /> vcll �T: 1 -,�tt o <br /> TANK OWNER TYPE F 2. INOMOUAL T• A. LOCAL AGENCY I DIS'TRICC I•S. STATE AGENCY AM <br /> TAY 1, CORPORATION r 3. PARTNERSHIP r S COUNTY AGENCY r 7. rEOERAL AGENCY <br /> TT'( (TK)HQ 4 a Call(916)322.9669 if questions arl" 4z1 <br /> INDICATE METHOD(S) 1. SELF-INSURED r 4 SURETY SONO T. STAT£FUND T' 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE T S. LETTER OF CREDIT r a. STATE FUND b CFO LETTER T 9B. OTHE{L <br /> ?C 3. INSURANCE T 6. EXEMPTION r 9. STATE FUND 6 CO 422 <br /> Checx one box,to intllce19 which ad":a,,ahoefd be used for legal notifications WKI IT-419. r 1. FACILITY r 2. PROPERTY OWNER (_ 3. TANK OWNER 423 <br /> `ycgal rla�fic>4Unns b wnge will Dn rrt t maLl a-urMess box I or 2 r.cheek&d <br /> CertrticatiCr�.1 tpr�RyA11 d nlof etbn prwld x GUe and 4cowate t0 lfp best of my kna ledge. 77425 <br /> 3 <br /> SIGN TIO v AN� �i' GATE 01 4T4 PHONE '-'1 L <br /> NAME OF APPLICANT(ennq 424 TRLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Forlocal use only) 42e 1998 UPGRADE CERTIFICATE NUMBER(F.Qr Ca/use only) 429 <br />