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UNIFIED PROGRAM CONSOLIDATED FORM g/g /�3 $�' PR a: <br />FAC It: <br />UNDERGROUND STORAGE TANKS - FACILITY yl p� ,3 <br />(one page per site) <br />TYPE OF ACTION ❑ I. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ❑ S. CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLC <br />V8 <br />SED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT TANK REMOVED <br />[36. TEMPORARY SITE CLOSURE <br />400 <br />I. FACILITY / SITE INFORMATION >_ <br />BUS INESSNAME(samsm FACRrt N"Ere DBA-Doig B.i..s MI 3 <br />FACILITY ID# <br />PR'DO <br />2 <br />O i <br />NEAREST CROSSS 7 <br />FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/D <br />TRICT4 <br />401 <br />❑ I. CORPORATION ❑ 5. COUNTY AGENCY <br />❑ 2.INDNIDUAL <br />❑ 6. STATE AGENCY' <br />4oz <br />BUSINESS ❑ 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL <br />TYPE <br />❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 401 <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY <br />TOTAL NUMBER OF TANKS <br />Is Facility on InReservation or <br />*If own. ofUST is a public agency: name of supervisor of division, section or gtFce <br />wM1icb operates <br />REMAINING AT SITE <br />trusdands? <br />the UST (This is Ibe concoct person for the tank records.) <br />404 <br />❑ Yes [INo 405 <br />4a6 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE <br />408 <br />-91 <br />LING OR STREET ADDRESS <br />409 <br />CITY 410 STATE -rX 411 ZIP CODE <br />412 <br />PROPERTY OWNER TYPE ❑ L CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/ DISTRICT ❑ 6. STATE AGE <br />qCY <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL A <br />ENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE <br />vs <br />MAILING OR STREET ADDRESS <br />416 <br />CITY yp <br />STATE 411 <br />ZIP CODE <br />419 <br />TANK OWNER 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />420 <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TY) gQ 44_ <br />Call (916) 322-9669 if questions arise <br />d21 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT N <br />ECHANISM <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD <br />423 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate wbich address should be used far legal notifications and mailing. ❑ 1 FACILITY ❑ 2. PROPERTY OWNER ❑ 3. TAN <br />C OWNER 423 <br />Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br />VII. APPLICANT SIGNATURE <br />Certification -1 certify that the information provided herein is true and accurate to me best of my knowledge. <br />SIGNATURE OF APPLICANT <br />DATE 424 <br />PHONE <br />425 <br />NAME OF APPLICANT (print) 426 <br />TITLE OF APPLICANT <br />427 <br />STATE UST FACILITY NUMBER(For local uc only) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (Fre lod use oay) <br />429 <br />Is 1998 Compliant? <br />UPCF (1/99 revised) fo 0 <br />