Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> ==UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page 1 of 1 <br /> TYPE OF ACTION rck onO <br /> 1.NEW SITE PERMIT r 3.RENEWAL PERMIT CHANGE OF INFORMATION(Specify change- r T.PERMANENTLY CLOSED SITE <br /> (Check item only) r 4.AMENDED PERMIT boot Use only) r6.TANKREMOVED 400 <br /> r S.TEMPORARY SITE CLOSURE <br /> E. <br /> . G - &il y I.FACILITY I SITE INFORMATION r OI <br /> BUSINESS E(Same as FACILITY NAME or DBA-Doing Business All 3 FACILITY ID Ji \I <br /> NEAREI R SS STREET FACILITYOWNER TYPE r 4. LOCALAGENCYIDISTR <br /> r 1. CORPORATION ] S COUNTYAGENCY' <br /> BUSINE STYPE ]' 1.GAS STATION r 3.FARM r 5.COMMERCIAL >QINDIVIDUAL r 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR X.6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is/adliq on Intlien Reservation or 'If owner of UST isa pu5lic egenq'.name of supervisor of <br /> REMAINING AT SITE f WSllanda7 ction division,seoraRce whion operates the UST. <br /> (This Is the canted person for the tank records.) <br /> 404 rYea rNo 405 4W <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> � c Oma,ch• ' ao -h <br /> MAILING OR STREET ADDRESS 409 <br /> W. 1'Yt e� <br /> ATE 411 ZIP CODE 412 <br /> CITY 410 <br /> S oc K�� GR a o <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCALAGENCY I DISTRICT r 6. STATEAGENCY 413 <br /> r 1. CORPORATION ['3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> • III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OVMER TYPE 2. INDMDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERAL AGENCY <br /> rTY(TK)HO 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METH00(S) 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 8. STATE FUND 6 CFO LETTER >499. OTHER: At Q:h�Q <br /> F 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Chock one Doxto iMicate which address NquM pe used IM bgal ndifraliona end mailirp. r 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Least otiT ion me I' a III l to the tank own <br /> VII PPIIrANTSIr�NATIIRP <br /> Codification: I codify that IM Mprmation pn vga0 herein is Yue and aosl to the t»et of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(pdn0 428 TITLE OF APPLICANT 427 <br /> STATE USTFACILITY NUMBER(Forbcal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal ase only) 429 <br /> /U <br /> UPCF(1199 revisetl) 5 Formerly SWRC13 Form A <br />