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NIFIED PROGRAM CONSOLIDATED ORM TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page _ of _ TYPE OF ACTION j' 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5,CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE (Check one item only) 4 AMENDED PERMIT local use only) r B.TANK REMOVED 400 r r 6 TEMPORARY SITE CLOSURE I.FACILITY/SITE INFORMATION I'FZ gQg BUSINESS NAME(Same as FAZILITY NALME or DBA-Doing Business As) 3 FACILITY ID X R NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT F 1. CORPORATION r 5. COUNTY AGENCY• BUSINESS TYPE r 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL r 6. STATEAGENCY• r 2.DISTRIBUTOR r 4.PROCESSOR r 6.01HER r 3. PARTNERSHIP r 7 FEDERALAGENCY• 402 403 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'g owner of UST is a public agency:name of supervisor of REMAINING AT SITE Wstlantla dmision,section cr office which opera the UST. (This is the Lontact person for the tank records,) 404 r Yes r No 405 406 IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 MAILING OR STREET ADDRESS 409 - CITY 410 STATE 411 ZIP CODE 412. PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING OR STREET ADDRESS 416 CITY 417 STATE 418 ZIP CODE 419 TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 420 ' r 1. CORPORATION r 3. PARTNERSHIP r S COUNTYAGENCY r 7. FEDERALAGENCY TY(TK)HO 4 4 - Call(916)322-9669 if questions arise 421 INDICATE METHOD(S) r 1. SELF-INSURED r 4. SUREW13OND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM F 2 GUARANTEE r 5. LETTER OF CREDIT r 8 STATE FUND a CFO LETTER r 99. OTHER: F 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CO 422 Check one box to Indicate which address should be used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTYOWNER r 3. TANK OWNER 423 Least notifications and meilin s anit be sent to the tank owner unless box 1 or 2 is checked Certdicabon: I certify that the information provided herein is sue and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(pnnp 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(Forklcel use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 m UPCF(1/99 revised) 5 Formerly SWRCB Form A *0-0