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-<<a <br /> zj <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> Pp- TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> _ a Pegg of <br /> 1.N3RENEWAL PERMIT <br /> TYPE OF ACTION I' NEW SITE PERMIT I. . CHANGE OF INFORMATION(Specify change- I- ' ERMANENTLY CLOSED SIT <br /> (Check one mem only) 1tical use only) �ANKREMOVED 400 4.AMENDED PERMIT <br /> I.6 TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY <br /> //NAME c,,DBA-Doig Bushels As) 3 FACILITY ID a <br /> FACILITY OWNER TYPE P 4. LOCALAGENCYIDISTRICT- <br /> IL4 IJ I II' r 1. CORPORATION [ 5. COUNTY AGENCY' <br /> BUSINESS TYPE [' 1.GAS STATION I. 3.FARM F 5. MMERCIAL 1 2. INDIVIDUAL I. 6. STATE AGENCY- <br /> I.2.DISTRIBUTOR I.4.PROCESSOR F 6.OTHER r 3. PARTNERSHIP ]' 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agencyname of supervisor of <br /> REMAINING AT SITE hustlands7 division,section or once which operates the UST. <br /> (This is me contact person for the tank records.) <br /> 404 ).'Yes No 405 406 <br /> If.PROPERTY OWNER INFORMATION <br /> PROPERTY ONMER NAME 4D7 PHONE 405 <br /> lint 0, <br /> MAILING OR STREET ADDRESS 409 <br /> I 410 TAE 411 21P CODE 412. <br /> -A� Ct, S <br /> PROPERTY OPMER TYPE F 2, INDIVIDUAL F 4. LOCAL AGENCY I DISTRICT F 6. STATE AGENCY 413 <br /> I 1. CORPORATION r 3 PARTNERSHIP I' 5 COUNTY AGENCY I 7 FEOERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE I. 2. INDIVIDUAL I. 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> I. 1. CORPORATION I. 3. PARTNERSHIP F 5. COUNTY AGENCY T 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) I' 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND I. 10. LOCAL GOV=T MECHANISM <br /> I. 2. GUARANTEE I 5. LETTER OF CREDIT I. 8 STATE FUND d CFO LETTER r 99 OTHER <br /> I. 3 INSURANCE I 6. EXEMPTION I 9. STATE FUNDS CD 422 <br /> Check one boa o iMicete which address Mould be used for legal rtWiraslions end mailing. I. 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423. <br /> Local no"ficabon maili a III t the own nlesa xl or is Wed <br /> Certification: 1 car*that the information provided herein is bue aro accurate,to the bast of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(pnnfl 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For WW use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> h� <br /> UPCF(1199 revised) 5 I(�2v} Formerly SWRC13 Form A <br /> I-� <br />