Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify Merlge- 11)<PERMANENTLY CLOSED SITE <br /> (Cheer one item only) 4 AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> I <br /> r 6.TEMPORARY SITE CLOSURE <br /> ` rl �r I.FACILITY/SITE INFORMATION <br /> BUSINESS AME(Same as FACILITY NAME or D Doing usinesa As) • 3 FACILITY IDa <br /> S finc <br /> NEAREST ROSS STREET 4.3j <br /> G.�t- 1. CORPORATION F 5. COUNTY AGENCY' <br /> BUSINESS TYPE ^_GAS STATION r 3.FARM r 5.COMMERCIAL t 2. INDIVIDUAL <br /> r 8. STATE AGENCY' <br /> r 2.DISTRIBUTOR F 4.PROCESSOR r B:OTHER F 3. PARTNERSHIP F 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKSIs hrAlily on Indian Reservation or 'If owner of UST is a Wblic agency:name of supenlsor of <br /> REMAINING AT SITE trus8ands? division,section or offwe wnirh operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 r Yes No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> iG e <br /> MAIL NG OR STREET A DRESS 409 <br /> 8' $outreel: <br /> city 410TAL 411 ZIP CODE 412. <br /> PROPERTY OWNER TYPE a2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> 1. CORPORATION I' 3. PARTNERSHIP r 5. COUNTYAGENCY I 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SAme & S <br /> rt <br /> MAILING OR STREETADDRESS 41 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT I 6. STATE AGENCY 420 <br /> I 1 CORPORATION r 3. PARTNERSHIP I 5 COUNTY AGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HO 4 4 - Q Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOO(S) F 1. SELF-INSURED r 4, SURETY BOND r 7. STATE FUND �F, 10. LOCAL GOV=TMECHANISM <br /> F 2. GUARANTEE F 5. LETTER OF CREDIT F 8, STATE FUND 8 CFO LETTER 1 yw OTHER: <br /> r 3. INSURANCE F S. EXEMPTION F 9. STATE FUND 8 CD ' ` 422 <br /> Check one,bos to kgicele which addre$ashould be used for legal holitiatlans text mailing. r 1. FACILITY 2. PROPERTYOWNER F 3. TANKOWNER 423 <br /> L 8' M mailin s will be sant 10 the tank oymer a less boz 1 or 2y; <br /> VII APM [CANT SIGNATI IRE <br /> Certi(atan: I camily that the iMonnation provided herein w We and accurate to the beat of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(peen 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fpbca/use 0*) 428 1998 UPGRADE CERTIFICATE NUMBER(Forbcal use only) 429 <br /> UPCF(1/99 revised) 6 Formerly SWRCB Form A <br />