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J <br />UNI -'ED PROGRAM CONSOLIDATED F-- fill <br />w <br />v <br />UNDERGROUND STORAGE TANKS - FACILITY <br />1,a[ 6\\o�\ ANKS <br />one page per sate) <br />Page _ of _ <br />TYPE OF ACTION r I. NEW SITE PERMIT r 3. RENEWAL PERMIT HANGE OF INFORMATION (Soeaty charge- r 7. PERMANENTLY CLOSED SITE <br />(Check one item only) IOtal use only)- r 4 AMENDED PERMIT y) r S. TANK REMOVED 400 <br />F 6. TEMPORARY SITE CLOSURE <br />I. FACILITY! SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doig Susteess As) 3 <br />`BJ L.ur, <br />FACILITY ID It <br />000 s� <br />NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE <br />CORPORATION <br />r 2. INDIVIDUAL <br />r ]. PARTNERSHIP <br />r 4. LOCALAGENCYIDISTRICT- <br />r 5. COUNTY AGENCY' <br />r 6. STATE AGENCY' <br />r 7. FEDERALAGENCY' 402 <br />BUSINESS TYPE r 1, GAS STATION r 3. FARM r 5. COMMERCIAL <br />r 2. DISTRIBUTOR r 4. PROCESSOR r 6. OTHER <br />403 <br />TOTAL NUMBER OF TANKS <br />REMAINING AT SITE <br />404 <br />Is faullry, on Inter Reservation or 1t Mater Mf UST Is a ouoec agency: name of suoervlsor of <br />ws0aras7 d..n, seorion or office ahkM Mlleratas the UST. <br />(This is Ne conta m Person for Me tank raWms,) <br />r Yes r No 405 405 <br />ti. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />Il <br />PHONE 408 <br />MAILING OR STREET ADDRESS 409 <br />T 3000 <br />CITY 410 <br />STATE 411 <br />C <br />LIP COD a12 <br />PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT <br />r 1. CORPORATION r 3. PARTNERSHIP r 5 COUNTYAGENCY <br />r S. STATEAGENCY 413 <br />r 7. FEDERALAGENCY <br />- III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />"LING OR STREET ADDRESS 416 <br />Z je.e� <br />CITY 417 <br />STATE <br />ZIP0 419 <br />9 62,0 <br />TANK OYMER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY DISTRICT <br />r t. CORPORATION r 3. PARTNERSHIP r S. COUNTY AGENCY <br />r 6. STATE AGENCY 420 <br />r 7. FEDERALAGENCY <br />TY (TK) HQ 4 4 <br />Call (916) 322-9669 if questions arise <br />421 <br />INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND <br />r 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND 8 CFO LETTER <br />r 3. INSURANCE r 5. EXEMPTION r 9. STATE FUND & CD <br />r 10. LOCAL GOV-T MECHANISM <br />r 99. OTHER: <br />422 <br />Cheri ane boa to Intliteta which address sMuk1 be usetl br legal nmdKatgns ora mailhg. r 1. FACILITY .PROPERTY OWNER r 3. TANK OWNER 423 <br />al notifications an, ma."n swill be sen[ tom an owner unless a 1 or tl. <br />Caranoatim'. I unM that the mformation WMvloetl herein Is we are accurate to me Best of my knowboge. <br />SIGNATURE OF APPLICANT <br />DATE 424 1 <br />PHONE 425 <br />NAME OF APPLICANT tont) 426 <br />TITLE OF APPLICANT 427 <br />GYk",-r CML" 9 t- <br />