Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDAT: FORM <br />• <br />UNDERGROUND STORAGE TANKS - FACILITY TANKS <br />(one page per rite) <br />>'r_Ur Aullury Page _ a _ <br />( 17vt ane U i F only) r 1. NEW SITE PERMIT r 3. RENEWAL PERMIT CHANGE OF INFORMATION !Softly Marge - r 7. PERMANENTLY CLOSED SITE <br />r 4 AMENDED PERMIT or; ,ovyJ r 9 TANKREMOVED app ) <br />r 6. EMPORARY SITE CLOSURE t1/ <br />1 I. SELFJNSURED r A. SURETY BOND r 7. STATE FUND r 10. LOCALGOVeT MECHANISM <br />F 2 GUARANTEE r 5. LETTER OF CREDIT r S. STATE FUND & CFO LETTER r99 OTHER <br />r 3. INSURANCE r S. EXEMPTION r 9. STATE FUNO d CO 422 <br />Chit ane hooeM folegal naeiamms am mFArq.Leval beDeOn.,, r- <br />° CILTY <br />L FACILITY I SITE INFORMATION Fk, D5 t (40 7 l� <br />aUSINESSNAME (Same as FACILITY NAMEUORA-Daeq Rusness Hal 3 FAACC,IIUTY 101 <br />CMIbCallon' CBlllfy That (he IaOIma1I011 plpvtlee nCell a Vile ani aCCL(a1e Io me oesl a my kI1e.VNege. <br />NEARE OSS STRE T apl <br />FACILITY OWNER TYPE <br />r i. LOCAL AGENCYIOISTRICT• <br />BUS ESS TYPE t. OAS STATION <br />F, I. CORPORATION <br />r 3. FARM r i. COMMERCIAL r 2. INDIVIDUAL <br />r s. COUNTYAGENCY <br />F Z. DISTRIBUTOR <br />r a. PROCESSOR r S. OTHER r 3. PARTNERSHIP <br />r S. STATE AGENCY- <br />GENCY,103 <br />,103 <br />r 7, FEDERALAGE1 apt <br />TOTAL NUMBER OF TANKS <br />REMAINING AT SITE <br />Is UKodY on IMM RaeaNaoon or V P1vrler of UST s a a w agenc,: name a ai+oalMaor a <br />mAOF,not,7 9negn semon ar off. wn=ooernee me UST <br />446 <br />(Thin U ale ca11t]Q arson lof Vle lafet NI0'a1) <br />r YM r 408 <br />No a05 <br />II. PROPERTY OWNER INFORMATION <br />P�ERTY OWNER NAME 407 <br />g. <br />PNONE apR <br />MAILING OR SVJcT ADDRESS 409 <br />CI 410 <br />ISTATE att <br />ILP CODE 412 <br />PROPERTY OWNER TYPE <br />r Z. INDIVIDUAL r <br />A LOCAL AGENCY/DISTRICT <br />r I. CORPORATION [ 3. PARTNERSHIP r 5. COUNTY <br />r i. STATE AGENCY 413 <br />AGENCY <br />r 7 FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME ata <br />PHONE 415 <br />G2.QJ <br />MAILING OR STREET ADDRESS alb <br />CIT/ 417 <br />S Ai 41 <br />ILP COO it9 <br />TANK OWNER TYPE r <br />r 1 CORPORATION 2. INDIVIDUAL r i. LOCAL AGENCY/DISTRICT <br />r 5. STAT —AGENCY AM— <br />[ 3. PARTNERSHIP r S. COUNTY AGENCY <br />r 7. FEDERAL AGENCY <br />TY (TK) HQ <br />4 <br />4 <br />I <br />I <br />I Call (916) 322-9669 if questions arise <br />421 <br />1 I. SELFJNSURED r A. SURETY BOND r 7. STATE FUND r 10. LOCALGOVeT MECHANISM <br />F 2 GUARANTEE r 5. LETTER OF CREDIT r S. STATE FUND & CFO LETTER r99 OTHER <br />r 3. INSURANCE r S. EXEMPTION r 9. STATE FUNO d CO 422 <br />Chit ane hooeM folegal naeiamms am mFArq.Leval beDeOn.,, r- <br />° CILTY <br />(2. PROPERTYOVVNER r 3 TANK OWNER 1237, <br />CMIbCallon' CBlllfy That (he IaOIma1I011 plpvtlee nCell a Vile ani aCCL(a1e Io me oesl a my kI1e.VNege. <br />SIGNATURE OF APPLICANT GATE <br />ata I ?HONE 425 <br />NAME OF APPLICANT (poop 4261 IDLE OF APPIUC,tNT <br />A27 <br />/ii /� A� <br />♦i <br />i /r / � � / / vn <br />