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NIFIED PROGRAM CONSOLIDATED ORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION r1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4 AMENDED PERMIT lacaluseonly) rVICTANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION <br /> BUSIN__­-..(Same as FAILITV NAME or DBA-Doing Business As) 3 FACILITY ID R <br /> w 49 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCVIDISTRICT' <br /> F 1. CORPORATION r S. COUNTYAGENCY' <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> F 8. STATE AGENCY' <br /> r 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 Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank recorde) <br /> 404 r yes r No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3 PARTNERSHIP r 5. COUNTY AGENCY r 7 FEDERALAGENCY <br /> 111.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 OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCV r 7. FEDERALAGENCY <br /> TY(TK)HO 4 1 4 1 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) ]' 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2 GUARANTEE r S. LETTER OF CREDIT r 8. STATE FUND 8 CFO LETTER r 99. OTHER. <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Check one box to indicate which address should ba used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTYOWNER r 3. TANKOWNER 423 <br /> Legal notifications and mailings will be sent to the lank own r unless box 1 or 2,s cracked. <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(Forlacal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only)� ////4����29,,,,,,LyyyyL������,,,,,, <br /> UPCF(1/99 revised) .[-.� �7 /0� FoWRCB Form A <br /> 7 � i � <br />