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ti UJOIED PROGRAM CONSOLIDATEO DRM <br /> X^\ TANKS <br /> Iry <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> one page per sate) .I <br /> I <br /> Page _ -it <br /> T`rPS OF ACTION r I.NEW SITE PERMIT r 7.RENEWAL PCAMIT r 5.CHANGE OF INFORMAL.ON 1Soeotjc+a1)ge- r T.PERMANENTLY C O$EO SITE <br /> (C.:ecx one item only) r ocar use ontyl 4 AMENDED PERMIT r A.TANK REMOVED doo <br /> r a.7_tAPORARYSITECLCSURE <br /> I.FACIUTY(SITE INFORMATION <br /> I <br /> 43US:NE3S NAME!Sams as FACILITY NAME or OBA-Oovq Business As) 3 FAClUTY' I I I I I I <br /> V1 p R t OD G A 5 4g; LI' 6VA MIq(LT F P, Go <br /> NEAREST CROSS STREET 401 FACILITY OV.NER TYPE ( 4. LOCAL AGENCYIOISTRICS' <br /> r 1. �-CRPORATION <br /> C 5. COUNTYAGeNCY' <br /> 3USINESS TYPE 1 AS STATION r 3.FARM r 5.COMMERCIAL r 2. PARTNE S (-3, STATE AGENCY- <br /> 2 DISTRIBUTOR r 4.PROCESSOR r 6.OTHER ra PARTNERSHIP ; [- 7, FEDERALAGENCY- <br /> i 401 402 <br /> TOTAL NUMBER OF TANKS :s iacury on Urdtan Reservation or -ft owner d UST's a=,=I c agener name ct suoenrmar of <br /> REMAINING AT SITE aysdanasl, unman%sewon or='fte"mKn coernes 7+e UST. <br /> Crim is me contae oerson for me nam records) <br /> A04 r Yes -No 4Q5 Am <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407PHONE 408 <br /> P1�ALwiN1�l�' R• S• At6;H 1,*Or9 - T31 q 4 <br /> MAILING OR STREET A00 ESS 409 '^ (� <br /> k, E w M 1 C` �b V /L 471 LIPCOOE a12 <br /> CITY dio I STATE <br /> �To r-bl 6 1 C �1 I �c IE;l <br /> PaGPERTY OWNER TYPE r 2 .NOMOUAL r 4. .00AL AGF--ICY I OISTRICT r i. STATE AGENCY 4:3 <br /> r :. CORPORATION (-��PARTNERSHIP i` C S. COUNTY AGE.4CY [ 7 FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNERNAME 414 I P40NE 415 <br /> - phraLw � ,� i <br /> MAIUNG OR STREET AOORESS 416 <br /> ITT 4i I STATE =18 ZIP COOE 419 <br /> TANK OWNER TYPE �3. <br /> iNON10UAL 4. LOCAL AGENCYIOISTRICT r i. STATE AGENCY =20 <br /> I r 1. CORPORATION PARTNERSHIP r 5. COUNTY.AGENCY r 7. F_OERALAGENCY <br /> C CCC <br /> i( TK)HQ 4 a - I I Call(916)322-9669 if cuestions Anse <br /> 1 <br /> P- MCC <br /> INDICATE MET-HOO(S) [- 1. SELF4NSUR r A. SURETY BOND r 7. STATE FUNO r 10. LOCAL GOVT MECHANISM <br /> r 2. GUARANTE, r.s. LETTER OF CREDIT r 3. STATE FUND b CFO LETTER r 99. OTHER 42Z <br /> r 3. INSURAN¢E r 6. O(EMPTION r 3. STATE FUNO 3 CO <br /> CTed one box io noicate wmtn aeries snould Doused for'gal noukatans and msrfir . r 1. FACILITY r Z. ?ROPERTY OWNER r 3. TANK o vNER 42; <br /> I aCai oglircltIgns and mailings win be em! to tam Cyinef&MI211 box 1 I <br /> 7 0 <br /> CMdkabon: 1 IN that the information erwsdso herein is we and aoaxate to ms best of MY krwnecge. Q� �H7r7.r�rE{ <br /> I <br /> ]A t z 5_ �. a 4j4 I C,r v <br /> SIG. 1i�1RE F �CA�NT�\-y 1 <br /> NAME OF APP CANT(pnnt) 425'I 'l OF APPLICANT © � 42� <br /> F <br /> UST FACILITY NUMBER(For4=1 use 00111y) 4251` *9c-4 UPGRAOE CERTIFICATE NUMBER liWmcat ole"Y) 429 <br /> 1 <br /> m <br />