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6 T. <br /> UNT ?D PROGRAM CONSOLIDATED FORM <br /> TANKS LL�� <br /> UNDERGROUND STORAGE TANKS - FACILITY � I�Ip 3 TD <br /> (one page per site <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ ? CHANGE OF INFORMA PION ❑ 7.PERMANENTLY CLOSED SITE .1 <br /> (Check one item only) ❑4.AMENDED PERMIT specify change locallime only ❑ 8.TANK REMOVED �J <br /> M. 1EMPORAR)SI I L CLOSG RF. 400 7 <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Satic m FACILITY NAME or DBA-Doing Business An 3 FACILITY ID# <br /> LIBERTY RURAL FIRE DISTRICT FA0003795 <br /> NEAREST CROSS STREET oal FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' <br /> BRUELLA RD ❑ 1.CORPORATION ❑ S.COUNTY AGENCY' <br /> BUSINESS ❑ 2.INDIVIDUAL <br /> ® I.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 3 PARTNERSHIP ❑ 6.STATE AGENCY' <br /> TYPE <br /> ❑2.DISTRIBUTOR ❑ 4.PROCESSOR [16.OTHER 403 ❑ 7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 1 404 ❑ Yes ®No nos 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> LIBERTY RURAL FIRE DISTRICT 209 368-0905 <br /> MAILING OR STREET ADDRESS 409 <br /> Same As Site <br /> CITY Oto STATE 411 ZIP CODE 412 <br /> Same As Site Same As Site Same As Site <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> LIBERTY RURAL FIRE DISTRICT 209 368-0905 <br /> MAILING OR STREET ADDRESS 416 <br /> 24124 N BRUELLA RD <br /> CITY 417 STATE41e 1 ZIP CODE 419 <br /> Same As Site Same As S Same As Site <br /> TANK OWNER TYPE ❑ 1.CORPORATION 1:12.INDIVIDUAL 114.LOCAL AGENCY/DISTRICT 116.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 44-024739 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ I SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE 1:15.LETTER OF CREDIT❑ 8.STATE FUND&CFO LETTERD 99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best 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(For local ue only) ate 1998 UPGRADE CERTIFICATE NUMBER(Far rood sue only) 429 <br /> UPCF(1/99 revise <br />