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U ED PROGRAM CONSOLIDATED M �D2 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION [' 1.NEW SITE PERMIT r 3.RENEWAL PERMIT F 5.CHANGE OF INFORMATION(Spepyychange- F 7.PERMANENTLY CLOSED SITE <br /> (Check one dem only) r 4.AMENDED PERMIT local use only) r S.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> )e I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or OBA .ng 8ra ss As3 FACILITY ID 4 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE F 4. LOCALAGENCY/DISTRICT- <br /> r 1. CORPORATION F 5. COUNTYAGENCY' <br /> BUSINESS TYPE F 1.GAS STATION F 3.FARM r S.COMMERCIAL F 2 INDIVIDUAL <br /> r 2.DISTRIBUTOR r 4.PROCESSOR F 6.OTHER r 3. PARTNERSHIP r 6. FEDERSTATEAL AGENCY- <br /> 403 <br /> F ]. FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or If owner of UST is a Public agency:name of superosor of <br /> REMAINING AT SITE trusWMs? division.seaicn or office mich,operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 r Yes FN. 405 4136 <br /> 11.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 I DISTRICT F 6. STATEAGENCY 413 <br /> r 1. CORPORATION r 3 PARTNERSHIP r 5. COUNrYAGENCY r I 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 OWNER TYPE F 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT F 6. STATE AGENCY 420 <br /> r 1. CORPORATION ]- 3. PARTNERSHIP r 5. COUNTY AGENCY F 7 FEDERALAGENCY <br /> TY(TK)HO 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r T. SELF-INSURED F 4. SURETY BOND F 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE F S. LETTER OF CREDIT F S. STATE FUNDS CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE r 6. EXEMPTION F 9. STATE FUNDS CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> L al noliflCatiOhis and ma=d <br /> be Sent <br /> to the lank owner unless box 1 or 2 is checked. <br /> Certification: I congy,that the information provided halsin is two and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(prim) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1996 UPGRADE CERTIFICATE NUMBER(For local vse only) 429 <br />