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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page persue) <br /> Pape _L of -31 <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT / �.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE O <br /> (CMG one dem only) r 4.AMENDED PERMIT locel use only) r B.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE O <br /> E. G r L FACILITY I SITE INFORMATION <br /> BUSINESS RAME(Same <br /> m FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID a <br /> NEARES R SSSTR E FACILITY OWNER TYPE r 4. LOCAL AGENCYIDISTRICr <br /> r 1 CORPORATION r 5. COUNTYAGENCY` <br /> BUSINESS TYPE r L GAS STATION r 3.FARM r 5.COMMERCIAL . INDIVIDUAL ]'8. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR )Fz� OTHER r 3 PARTNERSHIP r L FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is fauliry on lin3m.Reservation., T owner of UST 4 a NbIk agency:rem.of wain r of <br /> REMAINING AT SITE + "sharks. division,section or office which operates Be UST. <br /> 1 (Th4�tits contact Person for the tank reconds.) <br /> 404 r Yee r No 4% <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> e mac (0 7 46 LQ <br /> MAILINGORSTREETADDRESS 409 pGD �n <br /> �• k6 •/ ' <br /> TATE 411 ZIP DE 41 <br /> CITY s oe K-�- GA a o <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r S. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER.INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 5 0-4-1 BWYI lh� <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE418 ZIP DE 419 <br /> TANK OWNERTYPE 2. INDNIOUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATEAGENCY 420 <br /> r 1. CORPORATION ] 3 PARTNERBHIP r 5 COUNTY AGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOO(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV�=T��M.E.Cs�HANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND B CFO LETTER X. OTHER: Ai a:I L Z <br /> F 3 INSURANCE r 6. EXEMPTION r S. STATE FUND 8 CO 422 <br /> nnmE <br /> CMG one Iox to indimtewhits address ahouMMuseol fcr legal ratifications and mailing. r 1. FgCILRY 2. PROPERTYOWNER r 3. TANK OWNER 423 <br /> Least n m li ill tot t *own unless 1 cri <br /> VII <br /> Cenif.tion'. I cMKy Chet the iMormation previdad herein is Yue and acwrete to gre Mel o<my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(pnM) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(F tocaluseonly) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use arty) 429 <br /> 4 o� T to -G -coo <br /> UPCF(1199 revised)) 5 Formerly SWRCB Folrn A <br />