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03127/2001 14:38 22094683433 FIFTH FLOCIR PAGE 02 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - r-Aciunr <br />Iona pope per sol <br />Page ,.... or r <br />Tft Or ACriON I' 1. NEW SITE PERMIT r 3 R8NMMk PER NT I S. CHANGE OF INFORMATION (apeaYy ehsnge • r Y PERmmeNTLY CLOSED erm <br />fChw tCm "m only 6atf e.eer/y, r /. TANK REMOVED 100 <br />a AUENDED PMWI' <br />r B. TEMPORARY SITE CLOSURE <br />I, FACWTY 161% INFORMAT116N <br />1011011 MR ( some w FAc L11Y NAME Of DBA - DOWp BUtNU As! 3 <br />FACILITY ID I <br />�I <br />r t FAcmay pROPERTY ONMER r S. YANK OWNISR 423 <br />CmtUkalion; I Mat Sts weimdom Zim hmeen ;s bw and as ueu b 0% boli d My knaatledga <br />NATURE <br />�y2 <br />=3 4 'a` <br />0(1e 6►Vf M CArV:ar <br />NWIP, NOF ANTrTn �IJa�2rtl <br />I�r 42: <br />, <br />9121317 c1loal ITE Opt ^ <br />U N Gty 1Z� I I ,W <br />FACILITY OWNER TYPE• <br />r 4, LOCAL AosNeymisruc <br />: S. CORPORATION <br />r B. COUNTYA�l1CY• <br />)�NOMOUAL r 0. STATE AwcN - <br />BUSIKE$$ r3A$ STATION r 3. FARM r s. COuMERCIAL <br />r 2. DISTRIBUTOR r 4. PROCEBBOR r S. OTNER <br />r 3, PARTNERBHP r r. FED@RAL AGENCY• 4D7 <br />4Qi <br />TOTAL NUMBER OF TAN <br />REMAINING AT PRE <br />.e y a+ Mrvaaa9 a swrer �t • pu K apbwy nurse auparvmar <br />truaO/rltl.T OIwIOn, "aim or"" whlcn gmfam ev U6T, <br />/ !This a the cads! person !br IS* tank records.; <br />496 <br />404 <br />r Yes P19405 <br />II. PROPIM OWNW INFORMATION <br />PROPERTY OWNERNAMB <br />Cctrc'z <br />N <br />-—ltlti <br />w INOORIOrRIETADDREES 40 <br />CLZ- <br />t'D . 6vl 1mg <br />PAcl ry lrt ee, I <br />STATE 411 <br />C <br />ZP CODE 412, <br />` s 3,4 4,= <br />PROPERTY DVW TM r •I, LOCAL Aovcy 101STRiCT r fl, STATE AGENCY 419 <br />I t. CORPORATION r 3. PARTNERBHIP r S. COUNTY AGENCY r r FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TK.GwN N <br />Cc�1 C_a C.. T+SCS5 <br />PHONE a1s <br />�-�341�`t�`�� <br />MAWNC OR STREET ADDRZa 410 <br />LD Bo' o22 <br />Man-veco. 4 <br />411 <br />. <br />zr coot45 <br />Gl S -3 <br />TANK OMEKTYPPe N VIOUAL r A. E,OCAL AGR CY r DISTRICT R 4TAT% A68NOY 420 <br />r S. CORPORATION r 3, PARTNwHIP r 5. COVNWAo{NCY r F. FemmAodhCY <br />rY (TK) HQ 4 4 1 - Coli (91 C) 322-0668 0gyWions arise �+ <br />INIEWTV WHOM r 1. mur4NSURm r 4 SURETY BOND <br />r 2, oVARAKTU r a LETTER OF CRaDlr <br />r 3 iNSURANC4 r $ omm" ON <br />7. 8TATE FUND r S0. LOCAL 40Y=T NECMANISM <br />r I, >ITATE FUND a CrO,ILMER r ". OTHER: <br />r 4. BTA% FUND 6 co <br />a+ogt OIw wx to Ytd m who m tE'sw MvWd a rued for logo) nollAraians Pad malro <br />r t FAcmay pROPERTY ONMER r S. YANK OWNISR 423 <br />CmtUkalion; I Mat Sts weimdom Zim hmeen ;s bw and as ueu b 0% boli d My knaatledga <br />NATURE <br />�y2 <br />=3 4 'a` <br />" -3Tf — rr ,ZE <br />NWIP, NOF ANTrTn �IJa�2rtl <br />I�r 42: <br />UPCF (I= revised) 5 Fomwy $WRCS Form A <br />