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UNIFIED PROGRAM CONSOLIDATED FORM <br /> P2 a��lo 7�s <br /> 7I `( <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> on ' epersiteJ <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(SPaaly-change- r 7.PERMANENTLY CLOSED SITE <br /> (Cheek one item only) local use onl <br /> r 4.AMENDED PERMIT Y) TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Samaw FACILITY NAME or DBA-Doug Busine Ac) 3 FACILITY IDN <br /> u, Do/a79S <br /> ITTTTT <br /> NEARESTCROSSSTREET 401 FACILITY OWNER TYPE <br /> F 1. CORPORATION r 4. LOCALAGEENCDISTRICT' <br /> COUN <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM , 5.COMMERCIAL INDIVIDUAL `�irv. C� r S. STATE AGENCY' - <br /> r 2 DISTRIBUTOR r 4.PROCESSOR r 6 OTHER r 3. PARTNERSHIP r 6 STATE AGENCY• <br /> r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS is facility on Indo Reservation or 'It owner of UST is a puClic agenry:name of supervisor of <br /> REMAINING AT SITE IrvstlanOs? Eivision,section or office which operalea the UST. <br /> (This is the contact Penson for the tank recor0s.) <br /> 404 r Yes r No 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OVjpIERNAM E 40]� PHONE 40B �- <br /> MMLINGO K,>AODyE$S� ///V <br /> CITY ' 410 /KJ TATE 411 ZIP CODE 412 <br /> 4^t of leA- rsz D) <br /> PROPERTY OWNER TYPE 2. INDIVIDUAL </wT�(.,� r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP ( t w✓o t r 5. COUNTY AGENCY r 7 FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHON 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 411 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE2. INDNIDUAL ,n CCL- r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> r t. CORPORATION r 3. PARTNERSHIP r VbU � r 5. COUNTY AGENCY r]. FEDERAL AGENCY <br /> TY(TK)HO 4 4 1 1 1 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4 RETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE 5. LETTER OF CREDIT r B. STATE FUND S CFO LETTER r 99. OTHER <br /> IF 3. INSURANCE r 6. EXEMPTION r 9. STATE FUNDS CD 422 <br /> Cfack one Cox b urticate which aeereas ehouM be useA for legal nolirnatbns antl mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal notificationsmail' a will nt tP C1e 1 nK owner unless Cox 1 or 2 is Chirzked. <br /> VII APPII(`ANTqIrNATIIRF <br /> Certification: I cei that the reformation provrtatl herein u We an,l acptKdte to the best of my kno-adlis <br /> SIGNATIJREIOF LICANT DATE 421 1 PHON 8 C� 425 <br /> 9 07 I1 <br /> NAME OF PLICAN n 426 TITLAP <br /> E PLICANJ 42] O <br /> �� <br /> STATE UST FACILITY NUMBER(For mca/use"Y) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />