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UN ' ED PROGRAM CONSOLIDATED F�� 9 <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS I <br /> -- (one Page per site) <br /> TYPE OF ACTIONPage _ of _ <br /> (Check one item only) r I.NEW SITE PERMIT r 3.RENEWAL PERMIT r S.CHANGE OF INFORMATION(Saparly change- r 7.PERMANENTLY CLOSED SITE <br /> r 4,AMENDED PERMITlocal use only) r 8.TANK REMOVED 400 <br /> r 6 TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Soma as FACILITY NAME or DBA-Doing Business AAS)) 3 FACILITY ID R <br /> NEAREST C�/3 S E 401 )� ^ FACILITY OWNER TYPE <br /> 7 V\ CORPORATION r 4. LOCAL AGENCY/DISTRICT' <br /> BUSINESS TYPE r I.GAS STATION r 3.FARM `X45.COMMERCIAL r 2. INDIVIDUAL r 5. COUNTY AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 6. STATE AGENCY' <br /> 403 r 7. FEDERAL AGENCY- 402 <br /> TOTAL NUMBER OF TANKS Is facility an Inaian Reservation or 1f owner of UST is a ouolk aganty:name of sucervisor of <br /> REMAINING AT SITE vustlantls7 tlimslon,sa ion or Office which operates me UST. <br /> 4W (This is me mmact person for the tank reccres.) <br /> r Yes No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS409 - <br /> CITU 4 0 STATEE7!! <br /> C,11 <br /> 13 <br /> PROPERTY OWNERTYPE r 2 INDIVIDUAL r 4. LOCAL AGENCY I DISTRI413/ <br /> KI. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCYY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Sa4Lk, <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 /> F 1. CORPORATION r 3 PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 41E= Call(916)322-9669 if questions arise <br /> 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4, SURETY BOND STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r 6. STATE FUND S CFO LETTER r W. OTHER: <br /> r 3. INSURANCE r S. EXEMPTION r 9. STATE FUND 8 CO :--:42]2 <br /> CC. <br /> Check ono box to intlipte which address snouts be tank <br /> for legal notifications b. anE mailing. r 1 FACILITY 2 PROPERTY OWNER <br /> Lal '( I tl 1 11 be 11 h k b 2 Uerh tl r 3 TANK OWNER 423 <br /> r—a <br /> Certification: I certily that the information provketl herein is hue and aadrrate to the best of my knowletlge <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Far local use only) 429 <br /> lonnl <br /> i • <br />