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12/21/2010 TUB 13: 25 _,AX 2094683433 SJC 299 <br /> UNIFIED PROGRAM CONSOLIDATED rORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PL,RMIT APPLICATION -FACILITY INFORMATION <br /> (one form per facility) <br /> I — — 'W 7.Fr-.RMANr,.-ir FACILSTY CLOSURr <br /> TYVE OF ACPON NL",w 5.()iAN(,2OT-'NF0RtAATI0N' TRANWR PERMIT <br /> (Check 0�Wta n-11)) 3.RFNIMNI,FrHMIT ❑ 6.11-M 1,01Wxy FACILITY MGM <br /> GIL -T,-V'Jt0 <br /> - <br /> - , <br /> Vo-yAl,NUM�J:Z01:1ST ATFACILITY Fm.-f-x--ry u-)---y-j <br /> - <br /> gmic"We Gialy) <br /> BL)StNESS NANIE(SwIleds 1-0 cm Aism A-) <br /> A'p io, <br /> :aa Ci'fY <br /> 11 U5INESS S1 1"r ADI)RESS <br /> Z9 1/ ctz <br /> 405,. 405. <br /> E] JLYM=Rr2.No <br /> 1",JE:.DISTRInvoN . is tile facffity lomicdor/.diag Z(csz�rvalim or <br /> ❑ 3 <br /> Y_-ACfL:TY T-YPE, <br /> .MW <br /> pR.0CFSS0R ❑ 6.0--11M <br /> iDWINFO THO <br /> PROPERTY OW NCR NAME <br /> St <br /> -III VIP 41-, <br /> CITY IE 3 1?e <br /> "7777777 <br /> ..YA_NKO1,FR�qT0R NAME Pl-'ONE <br /> (;�,)1� e3 <br /> 428-4. STATL ZIPCOI)v <br /> CITY <br /> 64 - <br /> io <br /> ?"(mr. <br /> TANKOWVTiRNANIF <br /> ode ) <br /> W-A-11ANGADDRESS <br /> .ZIP C� <br /> 413, STATE 41) <br /> CITY ZIP C I <br /> 6.57ATE AGf-,NCy <br /> OWNERTYPF: ❑ 4.L CAL rNCYIDISTRICT MLNTY r.Gr'Ncy <br /> 0 AL IC <br /> 8.NON�CIVERNMC <br /> 7.rr DER AGCNCY NON-GOVERNMENT <br /> Ef <br /> _.uA <br /> Z"' <br /> -77,77`77, <br /> jai!.if there 41cJu1!Sti0:%5- <br /> Call thc State Board M.Lializatioll,fuel,rax:)Ms <br /> TY(TK)HQ A4- -7777777777�� <br /> 7777 <br /> 4.TANK OPERATOR <br /> Jcgai roti fica I ions and w.i ilings to; 1.FACILITY OWNLR TOR <br /> r <br /> OWN <br /> .TANK 'R 5J:AC11,TTY0PFJ1A <br /> DN,SCOHON,OR OFFICE <br /> T. <br /> CyRT111CATION: <br /> 1 eoytflthat tLlo itIfOl-Itl2tion provided fiercin is t-wD,accmatcl and in full tom Rana with leppl requirements. <br /> or' <br /> i,YPLICAN r SIC NATURE I)A T I.. 2-z <br /> Rana m', <br /> i21 1 <br /> 126 APPILACANTTITLE <br /> ReY.(Imov)-v2 w-WIV.Lill w ocs.org <br /> A99 <br /> CA M6-Z9V (606 :20 01 ZZ oaf 1 <br />