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L <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> ANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY ��/1 [Q <br /> •(one page per site) <br /> �g Page o <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT / ' CHANGE OF INFORMATIO J(Spec charge- ].PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> r 4.AMENDED PERMIT local use only) s 8.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSUR u <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same asFACILITYNAMEor DRA-Doting Business As) 3 CuLl <br /> FACILITY tokZ70 A) A <br /> • cJ 1 V,•v,i. 1 <br /> NEARE TCROSS STRE 401 FACILITY OWNER TYPE r 4. LOCALAGENCY/DISTRICT• <br /> F 1 CORPORATION r 5 COUNTY AGENCY• <br /> B <br /> USINESS I TVc 1 1,GAS STATION r 3.FARM ^COMMERCIAL r 2. INDIVIDUAL <br /> F 2 DISTRIBUTOR r 4.PROCESSOR r 8 OTHER r 3. PARTNERSHIP r 6. STATE AGENCY' <br /> F ]. FEDERAL AGENCY' <br /> 403 402 <br /> TOTAL NUMBER OF TANKS Is taplity on Indian Reservation or '8 owner of UST is a public agencyname of supervisor of <br /> REMAINING AT SITE / Irustlentls? division,section or office which operates the UST. <br /> (This Is the contact person for the tank records.) <br /> 404 r Yes r No 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME, <br /> HONE <br /> 407 PHONE 408 <br /> MAI ING OR STREET ADDRESS 409 <br /> D r <br /> CITY 410 STATE 411 zip C0 412 <br /> S f 4&y..-, c 9 <br /> PROPERTY OWNER TYPEINDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r S. STATEAGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5 COUNTYAGENCY r 7. FEDERALAGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Scl",-ems Gtv <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> F 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HO 4 4 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 B STATE FUND d CFO LETTER jt'Ig. OTHER_ <br /> r 3 INSURANCE r 6 EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Chetlr ane box to iMicne which atldreas aJaub be used for legal notifi ations arM mailing. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal Mificattlyms 'I t nk ownw unless Iox 1 or 2 Is <br /> Cendiration. 1 ceHrty that the information provided harem is sue and accurate to the ben of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fob <br /> real nae cs*) O 428 1998 UPGRADE CERTIFICATE NUMBER(Forbcal use oMy) 429 <br /> CRIZO <br /> did=h; <br /> UPCF(1/99 revised) J Cx*Uj/1i 6 V � eFortriterly 5WRC13 Form A <br />