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UNIFIED PROGRAM CONSOLIOA TEO FORM <br /> I <br /> I i <br /> I <br /> I <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS <br /> � (one Page perste) <br /> TYPE OF ACTION I-' t NEW SITE PERMIT An- _ Pi _ <br /> ICh.-x onartsm w1y) r 3.RENEWAL PERMIT F 5.CHANGE OFINFORMAT;CN iSoovry orange- I. 7 PERMANENTLY CLOSED SITE <br /> F a AMENDED PERMIT Euse only) <br /> r TEMPORARY <br /> 3.TANK REMOVED -00 <br /> S. PORARY SfTE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME w DBA-Otmg Busnazs As) 3 FACILITY:O m <br /> CAPITOL AUTO SALES <br /> NEAREST CROSS STREET 40t FACILITY OWNER TYPE <br /> r 1. CORPORATION r a. LOCAL AGENCYIOISTRICT• <br /> 3USINESS TYPE [- I.GAS STATION F 3.FARM Fxs.COMMERCIAL ,r 2 :NONIDUAL r S, COUNTY AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER 3. PARTNERSHIP C S. STATE AGENCY• <br /> 403 F T. FEDERAL AGcNCY• a02 <br /> REM <br /> TOTAL NUMBER OF TANKS Is(wary on IIIdWn Reserva,an w •Yawner o,UST s a aunt <br /> os <br /> 70TAIN UMBER OF I`y,-r s7 agwvy:name cf syoennsor at <br /> arvmon,lemon w alhtn wnKh avwa,ea;ne UST. <br /> ONE too (KNOWN) I Ym F h me oanlw oe m wme anx eca>I <br /> I � <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY ONMEft NAME a07 <br /> PHONE 408 <br /> JAGENDER SINGH <br /> MAILING OR STREET ADDRESS 409 7 <br /> 650 E. MINER AVENUE i <br /> CI TOCKTONa�ATE 4,1 I IP CD E 4,z <br /> CA 95202 <br /> PROPERTY OWNER TYPE X [- 2. �NOIVIOUAL <br /> F 1. CORPORATION 4. LQCALAGENCYIDISTRICr [ 5. STATEAGENCY 4+3 <br /> F 3. PARTNERSHIP [ S COUNTYAGFNCY F T FEOERALAGE4CY <br /> I <br /> III.TANK OWNER INFORMATION <br /> TANK OWNERNAME 414 <br /> SAME AS PROPERTY OWNER INFORMATION ABOVE HONE s <br /> Ia <br /> !AILING OR STREET ADDRESS 416 <br /> Clr' 417 <br /> STATE 418I <br /> F I CORPORATION LP CODE 4+9 I <br /> ANK OWNER TYPEI <br /> 2- �NONIDUAL r a. LOCALAGENCYIOISTRIC r S. STATEAGENCY 420 <br /> F 3. PARTNERSHIP <br /> r S. COUNTYAGENCY r T FEDERALAGENCY � <br /> TY;TK)HO 14 14 I I I I 11 I I Calf(916)322-9669 if questions arse N/A 421 <br /> :NOICATE METHOOISI [' PnmqIPtI1 Ty <br /> 1. SELF-WSURED r y SURETY BOND F ..^^ <br /> . i <br /> 7STATE FUND F 10. LOCALGOVsTMECHANISM <br /> r 2 GUARANTEE r S. LETTER OF CREDIT r 9. STATE FUND&CFO LETTER r 99. OTHER <br /> r 3. INSURANCE F 6. EXEMPTION r 9 STATE FUND d co 422 <br /> cr <br /> C1ecs b t b rh as snauM tx eG/ egal RIa s aIq mallrq. <br /> -iscIal nanhm,cm and m.0m s w II be senrto me Iane cwn v umesa boy 1 tr F= F 1, FACILITY r i PROPERTY OWNER F 3. TANK OWNER 423 <br /> 1 <br /> Ddrtdltaban: I tetiRy Illal In in,o..isa nwM is w9 arq xCyfale Io I"has,0t my YnoMaoge. <br /> SIGN RE OF AP I T I GATE 42s PHONE 425 <br /> u-, o, I z� sz 1 - Z s <br /> NAM FA PLICANT(pnm) 428 O APWJCANT <br /> MR . JAGENDER SINGH OWNER 27 <br /> STATE USTFACILITY NUMBER(farbcal ass amy) 4231 'Ssa UPGRADE 6ccRTIFILA TE NUMBER(Fcr lOml use onry) 429 <br />