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IFIED PROGRAM CONSOLIDATED <br />UNDERGROUND STORAGE TANKS - <br />RM /V` <br />TYPE OF ACTION r 1. NEW SITE PERMIT F 3. RENEWAL PERMIT )<5. CHANGE OF INFORMATION y(Sp�eafy- ch�naynge- r� <br />(Check one item only) r 4. AMENDED PERMIT local use only) �d7 1 r Q r B. <br />F 6 TEMPORARY SITE CLOSURE _n it_- I <br />T <br />UPCF (1199 revised) ' <br />p1 \11( � 16_Y qr 5 <br />I SAD -- ft A*FFo�erly SWRCS Form A <br />I. FACILITY / SITE INFORMATION <br />BUSI�t3jESS NAME (Same ae FACILITY NAM or DBA- -Doing Busines ) 3 <br />A a 5' � . G <br />NEAREST CROSS STNI:fj 401 <br />FACILITY ID • I {; <br />FACILITY OWNER TYPE <br />F 1 CORPORATION IF <br />Ji< INDIVIDUAL <br />r 3. PARTNERSHIP <br />1,' 4. LOCALAGENCY/DISTRICT• <br />5. COUNTY AGENCY` <br />1 6. STATE AGENCY' <br />r 7. FEDERAL AGENCY' <br />402 <br />BUSINESS7Y PE r 1. GAS STATION r 3. FARM r 5. COMMERCIAL <br />r 2. DISTRIBUTOR F 4. PROCESSOR A OTHER <br />403 <br />TOTAL NUMBER OF TANKS <br />REMAINING AT SITE <br />404 / <br />Is lacility on Intlian Reservation or 'g owner of UST is a public agency name of supervisor of <br />Wsllands? division, section or office which operates the UST. <br />(This is the contact person for the tank records) <br />r Yes XN. 405 406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 40] <br />• <br />PH NE 408 <br />rC 35 7-4?06 <br />MAILING RSTREET ADDR SS 409 <br />2.32 <br />CITY 4 <br />STATE 411 <br />ZIP CODE 4 J <br />PROPERTY OWNER TYPE <br />1 1. CORPORATION <br />P 2. INDIVIDUAL I 4. LOCAL AGENCY I DISTRICT <br />I' 3. PARTNERSHIP I. 5. COUNTY AGENCY <br />1 6. STATE AGENCY 413 <br />r 7. FEDERAL AGENCY <br />111. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />e <br />PHONE 415 <br />MAILING OR STREE RES 416 <br />CITY 417 <br />STATE 418ZIP <br />c <br />CODE 419 <br />4 I -k,5 q <br />TANK OWNERTYPE <br />F 1. CORPORATION <br />INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT <br />r 3. PARTNERSHIP r 5. COUNTY AGENCY <br />I 6. STATE AGENCY 420 <br />I' 7. FEDERALAGENCY <br />TY (TK) HQ 4 4 <br />Call (916) 322-9669 if questions arise <br />421 <br />INDICATE METHOD(S) r 1. SELFINSURED <br />r 2. GUARANTEE <br />F 3. INSURANCE <br />I 4. SURETY BOND 1 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br />r 5. LETTER OF CREDIT r B. STATE FUND S CFO LETTER 99. OTHER:T <br />r 6. EXEMPTION r 9. STATE FUND & CD <br />422 <br />Check one box to iMiceta which address sMuld be used for legal naRlwl'003 ontl mailing. 1' 1. FACILITY 2. PROPERTY OWNER 3. TANK OWNER <br />Local notifications an maili s wit sent to lh to k nless x 1 or is the <br />423 <br />Cedecation: I caddy that the information provided herein m true and accurate to the beet of my knowledge. <br />SIGNATURE OF APPLICANT <br />OATS 424 <br />PHONE <br />425 <br />NAME OF APPLICANT (print) <br />428 <br />TRLE OF APPLICANT 427 <br />STATE UST FACILITY NUMBER (For local use only) <br />428 <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 <br />UPCF (1199 revised) ' <br />p1 \11( � 16_Y qr 5 <br />I SAD -- ft A*FFo�erly SWRCS Form A <br />