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1 UfIED PROGRAM CONSOLIDATED F M =(i:)' TANKS <br /> UNDERGROUND STORAGE TANKS - FACILIT <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.-CHANGE OF INFORMATION(Spedfy charge- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4.AMENDED PERMIT la cal use an/yj S.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Datrg 8usine33 A4) 3 FACILITY 10 s <br /> -6-( cl �� f- D I Co <br /> NEPREST CROSS STREET 401 FACILITY OWNER TYPEr 4. LOCAL AGENCY/DISTRICT' <br /> I r.. r I. CORPORATION r 5. COUNTYAGENCY' <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM r S.COMMERCIAL r 2. INDIVIDUAL <br /> r 6. STATE AGENCY• <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is hWity an Incan Reservation or of owner at UST m a ouolk agency.name of sapervrsor of <br /> REMAINING AT SITE trustanUs? dmsion,section or office whictI operates de UST. <br /> (This is the cWtaot Person for Ne tartk ram ) <br /> 404 rYea rNo 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP 00 412 <br /> PROPERTY OWNER TYPE r 2 INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT IF 6. STATEAGENCY 413 <br /> r 1. CORPORATION ('3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE . 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 416 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDMDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOO(S) r I. 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 S CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND S CD 422 <br /> Check one box to indicate whits address 3r so be used for legal notRcationa ane mairelg. r I. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER a23 <br /> L M d 1' 'll a t l M k b 2' Marked <br /> CeNficatbn: 1"Ady that the infonnaWn prowled herein is wa and a=rats to the heel of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(Pdnt) 428 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For/ocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forkxal use ONY) 429 <br /> J <br />