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UNIFIED PROGRAM CONSOLIDATED FORM <br /> igeprske)UNDERGROUND STORAGE TANKS - FACILITYEE- - (oTYPE OF ACTION Page - - <br /> (Checkonastem oMy) r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> r 4.AMENDED PERMIT kcal use only) r RTANKREMOVED 400 <br /> L r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same"FACILITYNAMEorri -Doing Busineaa ) 3 FACILITY IDN <br /> 87D q NL Dais <br /> N ROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT• <br /> F 1. CORPORATION <br /> BU NESS PE r 1.GAS STATION r 3.FARM .COMMERCIAL r 2. INDIVIDUAL r 5. COUNTY AGENCY' <br /> r 2 DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 6. STATE AGENCY• <br /> r]. FEDERAL AGENCY• 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is fealty on Indian Reaervahon or •H owner of UST is a public agency:name ot supervisor of <br /> REMAINING AT SITE tmstlands? tliviskm,sectkn or office which,operates the UST. <br /> ' (This is the contact person for the tank record..) <br /> 404 <br /> r Yee XNo 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROP VMEE 407 PHONE 408 <br /> dao 7 - III <br /> MAILING OR STREET ADORES 409 <br /> CITY ^ 410 ^ STATE_ 411 ZIP CODE t O q <br /> S ia <br /> PROPERTY OWTIER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION F 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III,TANK OWNER INFORMATION <br /> TANK OV.Mr1ERRNNAME <br /> E 414 PHONE <br /> ^ 1 �s ��/q-�,�p PHONE 415 <br /> w r Illy C.-rr'W C.ab '--l.i r <br /> MAILING OR STREET ADDRESS 416 <br /> CRY 417 STATE 418 ZIP DE 419 <br /> TANK OWMER TYPE r 2. INOWIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> F 1 CORPORATION r 3. PARTNERSHIP r 5 COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 1 - I I I I I I I Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2 GUARANTEE r 5. LETTER OF CREDIT r 6. STATE FUND 8 CFO LETTER �99. OTHER: WF"_ '� <br /> r 3 INSURANCE r 6 EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Check one bos to indicate which atltlrees should be usetl for legal notifications and mailirp. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Limal di ionand <br /> n m " 'II sent to N tank nla or 2 is checked! <br /> Cerlifxzlion: I certify that the iMonnetion pmvitletl herein is true and savrate to ere beet of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(gird) 428 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For kcal use only) 428 1898 UPGRADE CERTIFICATE NUMBER(For kcal use only) 429 <br /> Lv _ <br /> UPCF(1/99 revised) 1 5 J� Formerly SWRCB Form A <br />