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FEB-21-2011 11:05A FROM: TO:4616342 P.1 <br /> -?MUD PROGRAN OOIVSOmATED FORM <br /> UPMERMOUND STORAGE TANK <br /> OPRRATiNG IMAM APPLICATION—FACILITY INFORMATION <br /> TYPE OF ACTION [3L NEW PERMIT • ()S.QLA. X OF INFORMATION [37.PERMANENT rMM[iTY ct osURE <br /> ICIr#ore umn m*l ❑ 3.RENEWAL PERI " ❑8.TEMPORARY FACILITY CLOSiJRR 119.TRANSFER I MMIT <br /> I. FAC nYINFORMATION <br /> • s. <br /> 'DOTAL &ROP UStb ,1Qt ITY FACILITY ID p <br /> Q-.TSS KAM Ua¢rFAI„�PYi�Acrla08R- V,��lluWwrAa1CN <br /> 1 1 <br /> BUSLVESS SITE AODDRRE��._•�• <br /> s <br /> FACILCCY TYPE I.MOTOR vautcu uaiNG ❑ 3.FUEL txsm'3L'nON to dw fxirOy tomued oa tadk e or <br /> 3.FARM 4.F a' 6.OTHtE Titin�°❑Yes o <br /> i <br /> IL pROPERT7l O"ER INFORMATION? <br /> , <br /> PRIOPERTY OWNER NAME <br /> ,, fi <br /> _t , <br /> MA NG ADDRESS �j {� i <br /> :�"7`7t` LSE_'. �t. �n(�t�'.l b��r�t� a,a <br /> My ♦ta STATE +/s. LIP <br /> .CL .7 <br /> M. <br /> TANK OPERATOR INFORMATION <br /> TANi:OPERATOUQWC <br /> {'r '1� `� •`rte ( � <br /> N <br /> MJ11Li- A <br /> CITY STAT4 ZIP CODE <br /> IV. TANK OWNBR INFORMATION <br /> .w <br /> PRONE <br /> 'TA- K OWNER NAME <br /> MA! ADDRESS , <br /> m. STATE s,a UPCODG s,9, <br /> CtI'Y <br /> OWNERTYPE. D 4.LOCAL AM XTII)ISTRiGT ❑ 3.COUWY AGEtKti ❑ <br /> 6.STATE Ati1=XCt' <br /> Q 7.FEDERAL s :E:+C1' ❑ tl.NgN-GOVF.Rt0aW- <br /> V. BOARD Ot; muAmATiON U3T MRAGE FEE ACCOQNT NU.'rIBER <br /> TY('TIC)HQ 44- _ coil the State Dowd of sq"la fim fact TON Div Wm%if ttlae ere4ue5tiGW <br /> YI.PERMIT SOLIDER wFORMATION <br /> 473 <br /> i.FACltdl'YOWNER Q A.T/[NiCOPERATOR <br /> tyyM 1 snd sad ieyat Iw(ifioodons oc+d n c irRs to' S.FAcit.tTY OPERATOR <br /> D 3.TANK oVb'NER 13 �. <br /> Stil't'1lViSOR OP DIVlSUIN,Sf,CTION,QE: *FtCE(R"Ated Far Pab6c A ()O SY) <br /> VII.APPLICANT SIGNATM <br /> cerrrrglcATio not die • Bolt •�his Is s of is mn Iiestiee.� <br /> DA E <br /> APPI.IC Z 912,011 209 2111 zec7©D10 <br /> APPLI NAME(piei) ApPG[CANT IT <br /> L A ; <br /> UPC>t VST-A Rev.(IVZtt(171 <br /> � .J -r`�.nrn�nn-sem c.inw!tor1U0" AT M%TTa Q`T :AT TT T7 004 <br />