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--- -- --------------- --- r .IF• PROGRAM CONSOLIDATEQO * � 3 TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page _ of _ TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify[/range- r 7.PERMANENTLY CLOSED SITE (Check cine item only) r 4 AMENDED PERMIT local usa oMy) r 6 TANK REMOVED 400 r 6 TEMPORARY SUE CLOSURE I.FACILITY I SITE INFORMATION { BUSINESS NAME(Same as FACOLITY NAME or DBA-Doing Business As) 3 FACILITY IDN 1 NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCALAGENCY101 CT• F 1. CORPORATION r 5. COUNTY AGENCY• BUSINESS TYPE r 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL r 2.DISTRIBUTOR r 4.PROCESSOR r 6 OTHER r 3. PARTNERSHIP r 6. STATE AGENCY• - r FEDERAL AGENCY 402 5 403 TOTAL NUMBER OF TANKSIs facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of REMAINING AT SITE trustlands? division,section or office which operates the UST. Ck- ' "a (This is me contact person for the tank records.) 404 r Yes r No 405 406 H.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 5. STATE AGENCY 413 r 1. CORPORATION F 3. PARTNERSHIP r 5 COUNTY AGENCY r 7. FEDERAL AGENCY Ill.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING OR STREET ADDRESS 416 CITY 417 STATE 416 LIP CODE 419 TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERALAGENCY TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM r 2. GUARANTEE r 5. LETTER OF CREDIT r a. STATE FUND 8 CFO LETTER r 99. OTHER: F 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 Check one Wx to indicate which address s='ked used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANKOWNER 423 L al notrn tion an mailin will b.:. to me tank owner unit ss fact,1 or 2 is ch d. Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local use only) ata 1998 UPGRADE CERTIFICATE NUMBER(For local use dully) 429