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UNIFIED PROGRAM CONSOLIOATE'n FORM <br /> UNDERGROUND STORAGE TANKS — FACILITY TANKS <br /> (one page per site) <br /> I YPE OF ACTION r t.NEW SITE PERMIT r 3.RENEWAL PERMIT Page — « <br /> (GYeut one rtam only) CHANGE OF INFORMATION lSneofy Marga. r7.PERMANENTLY CLOSED SITE <br /> r 4 AMENDED PERMIT oca use oWy) r aTANKREMOVED 400 <br /> r a.TEMPORARY SITE CLOSURE Y <br /> I.FACILITY I SITE INFORMATION Pk.Ob 1440 7 <br /> aUSINESS NAME ISame as FACILITY NAME ar ORA-Deep awshess As) 3 FACILITY 101 <br /> (/7 Lt �(��8 I' <br /> NEARE TOSS STRE T a01 FACILITY OWNER TYPE <br /> r 1. CORPORAT ON r i. LOCAL AGENCY/OISTRICT• <br /> BUS ESS TYPE t.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INOMDUAL r s. COUNTYAGENCP <br /> r 2 DISTRIBUTOR r a PROCESSOR r 6.OTHER r 3. PARTNERSHIP r a. STATE AGENCY- <br /> 307 r ] FEDERAL AGENCY' 402 <br /> TOTAL NUMBER Of TANKS :s raaYry on InWan Reservauen or V ewrler W UST s a ayolq agency:name W suoervuW W <br /> REMAINING AT SITE bye8ar11s7 WnNpt swan ar o f.wt=aovmes bee UST <br /> 404 (Tiffs a aNr cantor oersm lar Vte tarty rwaoa) <br /> r Yes r No 405 4oB <br /> II. PROPERTY OWNER INFORMATION <br /> PE^^RTY OWNER NAME 307 PHONE 408 <br /> S+C� <br /> MAILING OR SVJJET ADDRESS 309 <br /> CI 410 <br /> ISTATE att ILP CODE 412 <br /> PROPERTY OWNER TYPE r Z. INDIVIDUAL r 4 LOCAL AGENCY/DISTRICT r i. STATEAGENCY 413 <br /> r t CORPORATION [ 3. PARTNERSHIP r 5. COUNTY AGENCY <br /> C 7 FEDERAL AGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME Ale <br /> PHONE 415 <br /> ✓ QAJ <br /> MAILING OR STREET ADDRESS 416 <br /> CIT" 317 <br /> S Ai 41 ILP Cp0 it9 <br /> TANK OWNER TYPE r 1 CORPORATION 2. INDIVIDUAL r 3, LOCAL AGENCY I OISTRICT r S. STATE AGENCY AM <br /> r r 3. PARTNERSHIP <br /> r 5. COUNTYAGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise <br /> 421 <br /> INDICATE METHODS) j' t, SELF4NSUREO r 4. SURETY BOND r 7. STATE FUND <br /> r 10. LOCAL GOVT MECHANISM <br /> F 2 GUARANTEE r 5. LETTER OF CREDIT r 9. STATE FUND S CFO LETTER r99 OTHER <br /> r 3. INSURANCE r S. EXEMPTION r 9. STATE FUND d CO 422 <br /> ------------------------------ <br /> Chit onebox to Intliyale whimatltlrees enowtl be used ter Iegel"fteepns am ma&q. <br /> Lena nodi tl 0 will be t h actor r1, - CILTY ( 2. PROPERTYOWNER r 3 TANK OWNER 23 <br /> INT qtf'NATI IPF <br /> CMIfiCaaOn' Cala(y Thal(na II1tOrmarl011 prWga]herM iy bye arq af/yral9lo Ine beA OY my klpeNpge <br /> SIGNATURE OF APPLICANT GATE424 I PHONE 425 <br /> NAME OF APPLICANT(pnn0 426 TOLE OF APINUCANT 427 <br /> STATE UST FACILITY NUMBER(For rocs/use onyl 428 '998 UPGRADE CERTIFICATE NUMBER IFw=v use aI 429 <br /> YU acid `� � - /��o (�Pgll of <br /> -Sr' -1-0e. ;te tQ�+ � � <br />