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UN IED PROGRAM CONSOLIDATED F RM <br /> F/r00o 7D.), TANK <br /> UNDERGROUND STORAGE TANKS - FACILITY Gj3 <br /> (one <br /> -- b� Page of <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT CHANGE OF INFORMATION Spedty name- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) 4 AMENDED PERMIT local use ady) 8.TANK REMOVED 400 <br /> r <br /> r 6.TEMPORARY SITE CLOSURIV <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Devm Business As) 3 FACILITY ID K <br /> L <br /> NEAR , <br /> EET ) - �FA�ILITY ONMER TYPE ]'4. LOCALAGENCVIDISTRICT• <br /> /g4` CORPORATION ]' 5. COUNTY AGENCY' <br /> BfJSINESS TYPE r 1.GAS STATION r 3.FARM S.COMMERCIAL r 2. INDIVIDUAL <br /> r 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR r 4.PROCESSOR r B.OTHER r 3. PARTNERSHIP r 7. FEDERALAGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is fadlity on Indian Reservation or 'B owner of UST is a public agency:hame of supervisor of <br /> REMAINING AT SITE trustlandsT drosion.section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 rYes xo 405 ' (.;to ?) <br /> II.PROPERTY OWNER INFORMATION .ZdJ ( I p <br /> PROPERTY ONMER NAME � PHONE <br /> _7 <br /> q,3Ijj_ <br /> MAILING OR STREET AD S 409 <br /> CIT- 410 STATE 411 ZIP C DE 412 <br /> PROPERTY OWNER EINDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 //yy PHONE 415 <br /> Is WJ/ <br /> MAILINGORSTREETADDRESS 416 <br /> CITY 417 STATE 418 ZIPCODE 419 <br /> TANK OWNER TYPE INDIVIDUALr 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 420 <br /> r 1 CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7 FEDERAL AGENCY <br /> IV <br /> F(TK) O 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) F 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT r B. STATE FUND 8 CFO LETTER r 99 OTHER,t)M <br /> F 3. INSURANCE r 6 EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Check one box to intliceta which address ahouM be usatl for legal notifications ark!mailing. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER -023 <br /> L (R f tl I 11 be tl th t k bo 1 2 Ischecked <br /> VII PPI Ir.ANT RitIdATIVIsic <br /> Ceddoatlon: I cantly that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(pMt) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For oral use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> ' af�lljvlvv <br /> UPCF(1199 revised) Z3 /va ��r�3 - 6 pOH Formerly SWRUCB Form A <br />