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12/01/2003 16-09 2094683433 FIFTH FLOOR PAGE 02 <br /> 4W�PROGRAM CONSOLIDATED FIF <br /> TANXS 6 /277737 <br /> UNDERGROUND STORAGE TANKS-FACILI(OnV <br /> rypl OF ACTION In 1.NEW PERMIT e3,RENEWAL PERMIT a pap per site) to or- <br /> (Check ono item ordy) ❑ C3 S.CHANOE OF wyoRmAmN [3 7.PERMANENTLY 4'LOSED,9rrl[ 400. <br /> 4 AMENDED PERMIT(Specify change)6:TBM`tOXARY SITE CLOSM 8-TANK REMOVED <br /> iiI.44J., M 4-1 ........77 <br /> _X <br /> NAME 11---JWTYXAZKB Or COA-OWN 11.9 :.j <br /> IN <br /> BUSID <br /> x FACILI <br /> 'A 12-ecks lj�ztlAgo."J IDO <br /> ..(f q-32-3 2- 0 72 (c) <br /> NEAREST CROSS S I <br /> 491. <br /> FACILITY OWNEJt TYPE 4.L ALAGE YDIS 4 <br /> BUSINESS 1. AS ED I-CORPORATION El 5.COUNTY AGENCY- <br /> ION 3.FARM El 5,COMMERCIAL---447- W2.INDIVIDUAL 13&STATE AGENCY' <br /> TYPE ❑2,DISTRUKITOR ❑4.PROCEMR Q 6.OTHM 3.PARTNERSHIP 7.FEDERAL,AGENC-y* <br /> TOTAL UMBER OF TANKS 414. It IaCilitY On Indian R0ftVtfiWn_4 5 ;;Mft-0f UST is a p ub]ir muncy:"me of swervaFf of div <br /> REMAINING AT SITE or trust lands? Ofr2etl which OPOW21 the LIST. This is 1�hc contact Petwa for the=it records.) <br /> Yu &NO <br /> # 'OF <br /> PROPERTY <br /> INZCL <br /> PHONE <br /> MAILING OR S 1!T ADDOWS 6-,32- 679 <br /> T6 <br /> CITY 410. STATE a' 4j <br /> I'D4 Loc iz 2. 1 <br /> PROPERTY ER TYPE, I CORPORATION U 2.JN5rviDU1AL_Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 41ti <br /> ❑3.PARTNERSHIP ❑S.COUNTY AGENCY ❑ <br /> 7.FEDERAL A-3ENCY <br /> -.7 <br /> ,4 <br /> .......... <br /> H W. <br /> n <br /> TANKO &NAME j�j, <br /> PHONE <br /> 14 Ad Q 41J. <br /> MAILING O STEWT <br /> C, W, �'A, 416. <br /> cn <br /> I CL-K-rVj 417. i STATE 416, 2D DE <br /> _TANK OWNER TYPE <br /> _ff1._C0­RP_0_RA_T1_0XT-INDIVIDUAL U 4.LOCAL AG1NtWDff M_­C_T7CT6.STATE�AGENCY <br /> 3.PARTNERSHIP S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> _D�)HQ 44- <br /> (94 arise <br /> 322-9669 if '__tions * <br /> QL <br /> .......... rl:rill: <br /> ......... <br /> INDICATE MFTHOD(s) C)1.sELjijN-SrjM <br /> 04.3 �Iio" ig 7.SrATrz FUND ul 0 LQr.AL GOVT MECHANISM 421 <br /> "P <br /> �URANCE 0 S.LETTER OF C.%Wrr 13 C STATE FUND&CPO LETTER C3 99:oTHEju <br /> PKw__ 6.EXBOTION 0 9.STATE FM Se CD <br /> Nil <br /> Check one w4to w wil addressghbuitj tv <br /> 1.7 to inju <br /> Legal ROdficldcus ISM mailing will be JDAtio the talc owner utM box 10,2 is checked FACILITY ❑2. PROPERTY OWNER 43.TAN.,<OWNER 4.23. <br /> ...................... <br /> the tRfcmlldm PVAcd krait,is 17uw and soomato to 6b:be <br /> Q.fmy kwvvl6k& -,X <br /> SIGNATURE OF WANTI--r-1 .DATE PHONE <br /> e-3 <br /> NAME OF APPLICANT(priit 72-6 nTLSOFAPPLICANT <br /> G 0.,-/z -P/_ 0w/v,F -2 , <br /> STAT UST FACILITY NUMBER(Amaay.01*) 428- -1998 UPGRADE CERTIFICAT13 NUMBER(Annoy use Baty) 42t <br /> (See Data Element 1,above. <br /> VPCP Hwfwra-a(I/qp). huP!/twww-unidacs.org Rev.Mum <br />