Laserfiche WebLink
j UNIFIED PROGRAM CONSOLIDATED FORM <br /> f v I <br /> UNDERGROUND STORAGE TANKS — FACILITYI <br /> !one page per site) <br /> TYPE Of ACTION r 1.NEW SITE PERMIT Page _ of _ <br /> (Cllepx one CT IONly) r 3.RENEWAL PERMIT r S.CHANGE OF INFORMATION(Saecty f4reP r 7.PERMANENTLY CLOSED <br /> r 4 AMENDED PERMIT 0") IF B.TANK REMOVED a0p y <br /> r B.i EMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> StISINESS NAME �sFACIUTY NAME g08A-Owgl�Ay( 3 FACILITY 10 <br /> `D ` <br /> T <br /> FACILITY OWNER TYPE <br /> lujCl' CLA C 1. CORPORATION C a. LOCALAGENOYIDISTRICT• <br /> SUSINESS TYPE r1.GAS STATION r I FARM C i COMMERCIAL r Z. INDIVIDUAL r 5. COUNTY AGENCY• <br /> r 2.DISTRIBUTOR r4 PROCESSOR r S.OTHER r 3. PARTNERSHIP I C O STATE AGENCY- <br /> 403 r 7 FEDERALAGENCY- 402 <br /> TOTAL NUMBER OF TANKS :s faraay on na an Raaerrawn P •6Ow11Y d UST s a PuoYc again:name cl wPen+aar a <br /> REMAINING AT SITE Yusoixbe? orvwm,tenvon ar at6u r.nlrn olsrMes me UST <br /> (TMs Is A mnaa uvvaon M ela Mlel nNsn¢i l <br /> d06 r Y.. n.N� .0B <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 <br /> MAIL/ OR STREET ADDRESS a09 - <br /> LA <br /> er f <br /> I 0STATE alt LIP CODE '1 <br /> q,Y <br /> PROPERTY OWNER TYPE r 2 INDIVIDUALr A :OCAL AGENCY I DISTRICT r s.. STATE AGENCY <br /> r . Poata <br /> CORRAT ON 1 PARTNERSHIP r 5. COUNTY AGENCY r 7 FEDERALAGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME ata 1 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> I <br /> r a1 <br /> STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2 INDIVIDUAL r 4. LOCAL AGENCY l01STRICT C A STATE AGENCY 420 <br /> r I. CORPORATION <br /> C 3. PARTNERSHIP r i. COUNTY AGENCY r 7 FEDERAL AGENCY <br /> I <br /> TY!TK)HO 4 1 4 I I Call(916)322-9669 if Questions ansa 421 <br /> INDICATE METHOD(S) [- 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 7 GUARANTEE r 5. LETTER OF CREDIT r 9. STATE FUND a CFO IETIER C 9B. OTHER: <br /> r 3. INSURANCE r S. -%EMPTION r 9. STATE FUNO a CO 422 1 <br /> Clterxa aM xlaimla wmal aaaeas srlPtao be used for"Is nPlbmmtu mom. C 1. FACILITY r 2 PROPERTY OWNER r 3. TANK OWNER 423 <br /> R oox catM 1 be ern ne me w <br /> Caneiritim' cents fI1M me RRIXR1811P11 awloae nxan is aw aro ama,e le tna wat of mY en"mage. <br /> SIGNATURE OF APPLICANT I DATE 424 I PHONE 425 <br /> NAME OF APPLICANT(pann a28 TITLE OF APPUCANT 427 <br /> STATE UST FACILITY NUMBER(Forpa c"l 4281 '956 UPGRADE CERT.FICATE NUMBER(FVrb®I+a V) 429 <br />