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UNIFIED PROGRAM CON SOLIDATED RM <br /> [[= <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> TYPE OF ACTION F 1.NEW SITE PERMIT r 3.RENEWAL PERMIT ]� 6 CHANGE OF INFORMATION 5 Page _ of _ <br /> (Check onelfem only) (peci/y,change- I• ].PERMANENTLY CLOSED SITE <br /> I. 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> I.6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION S <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IDs •: <br /> 1-761 U W Q C ri <br /> NEARES ROSS TREES 401 FACILITY OWNER TYPE I 4. LOCAL AGENCY/DISTRICT' <br /> ff _ F 1. CORPORATION <br /> BUSINEus TYPE I 1,GAS STATION F 3,FARM I- 5.COMMERCIAL F' 2. INDIVIDUAL COUNTYAGENCY' <br /> I. 2.DISTRIBUTOR I. 4.PROCESSOR �yjy� OTHER r 3. PARTNERSHIP I-r 6. <br /> 403 STATE AGENCY' <br /> ]. FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKSIs facility on Indian Reservation or If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE tnustlands4 diyision,section or off-whip,oparatea the UST. <br /> 400 (This is the contact person for the tank records I <br /> I•Yes r No 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY DOWNER NAME 407 <br /> nPHONE <br /> H aO p{40G ru- ) 7 J / <br /> /l <br /> MAILING OR STR#T ADD 409 A <br /> r u U� <br /> CITY V i-/-O G STATE ZI <br /> 11 P CODE2 - 1 G 1 <br /> PROPERTY OWMER TYPE I'2. INDIVIDUAL LOCAL AGENCY I DISTRICT F 6. STATE AGENCY 413 <br /> I 1 CORPORATION 1 3. PARTNERSHIP COUNTY AGENCY I- ] FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> C <br /> MAILING OR ST E ADD S 415 <br /> CITU dt] TATE 418 ZIP CODE 919 <br /> S 4 C� `2 S; a-l <?9 7 <br /> TANK OWNER TYPE F 2. INDIVIDUAL LOCAL AGENCY I DISTRICT I.6. STATE AGENCY 420 <br /> I. 1. CORPORATION I' 3. PARTNERSHIP F 5. COUNTYAGENCY IF ]. FEDERALAGENCY <br /> TY(TK)HQ 4 1 4 1 - I I I I I I I Call(916)322-9669 if questions arise 4z1 <br /> INDICATE METHODS) I' 1. SELF-INSURED r 4. SURETY BOND F ]. STATE FUND 10. LOCAL GOV=T MECHANISM <br /> I' 2. GUARANTEE F 5. LETTER OF CREDIT I 8. STATE FUND 8 CFO LETTER F 99. OTHER: <br /> F 3. INSURANCE F 6. EXEMPTION I. 9. STATE FUND 8 CO 422 <br /> Chat aro box to Indicate which address should be used for legal notifications and mailing. I 1. FACILITY I. 2. PROPERTY OWNER TANK OWNER 423 <br /> Legal R n ilio <br /> and m s will be sent to the tank owner unless box 1 or i ck <br /> VII APPIl('.ANTqInNATIIRF <br /> Certification'. I certify that the information provided herein is true and accurate to the beat of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(pnnf) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 429 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 q� I-7, 9 q Formerly SV,/RCB Form A <br /> ,. „'t 1X4( q-(6.qI � <br />