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UI IED PROGRAM CONSOLIDATEDIPM <br /> saa/ <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page persue) <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION fSpeay change- 7.PERMANENTLY CLOSED SITE 6 <br /> (Check One item only) r 4.AMENDED PERMIT local use arty) [ a.TANK REMOVED 400 (� <br /> r 6 TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION ( I <br /> (NESS NAME(Same as FACILITY NAME m DBA-0009 Business As) 3 FACILITY ID a <br /> T 401 FACILITY OWNER TYPE ],' 4. LOCAL AGENCYIDISTRICT- <br /> r 1 CORPORATION [ 5. COUNTY AGENCY <br /> BUSINESS TYPE r 1.GAS STATION r 3.f M r 5.COMMERCIAL r 2. INDIVIDUAL <br /> r 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 7. FEDERALAGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Inwhan Resenodi m m 'K owner of UST is a publk:agency:name of supernsm of <br /> REMAINING AT SITE trustlands? dymi section m office whlcil operates Ne UST. <br /> (This m the contact person for Ne tank re ioni <br /> 404 ryes r No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP CODE 41 <br /> PROPERTY OWNER TYPE r 2. INDNIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 41B ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) (' i. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=TMECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r B. STATE FUND 8 CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATEFUNDSCD 422 <br /> CMG one box t0 iMOs[e which ed0ress shouts M useE fm legal notifications arts maiNng. r 1. FACILITY r 2. PROPERTY OWNER r J. TANK OWNER 423 <br /> el nmRcations end well to!he tank owner unless box 1 or is its ed. <br /> VII APPIIrAPJTqIrMATIIRF: <br /> Canlftntion: I cen4y that Ute iManneOon Wimoded Nrein ie nota and accurate to me Mat of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(pont) 428 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fm cost use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fm local use only) /4229,,.,f+��1y� <br />