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I� UN ` ED PROGRAM CONSOLIDATED F - iM <br /> • <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> y Page i of _ <br /> TYPE OF ACTION D[t NEW SITE PERMIT r 3.RENEWAL PERMIT I 5.CHANGE OF INFORMATION(Specify change- I 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) _J <br /> r a.AMENDED PERMIT local use only) F 8.TANK REMOVED 400 <br /> r 6 TEMPORARY SITE CLOSURE 0 <br /> I.FACILITY!SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or Dbing Business As) 3 FACILITY ID 9 <br /> NEAREST CROS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT- <br /> F 1. CORPORATION <br /> r 5. COUNTY AGENCY- <br /> BUSINESS TYPE GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> F 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR r 4.PROCESSOR F 6.OTHER r 3. PARTNERSHIP I 7 FEDERAL AGENCY- 402 <br /> 403 <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 trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 Yes X 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 40 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> RT f _tw CA - 4 03 P <br /> PROPERTY OWNER TYPE,�, F 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> DCI. CORPORATION r 3. PARTNERSHIP F 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK QWNER NAME 414 PHONE 415 <br /> RC0 P <br /> MAILING OR STREET ADDRESS 415 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> 1x1. CORPORATION F 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND F 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT F S. STATE FUND&CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one bdx n indicate which address should be used for legal notRoations and mailing. F 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER a23 <br /> Le al noMicauons and marlin s wd1 be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: I certify that the information provided herein is We and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE A 3 424 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OFA -1 ICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For lox use only) 429 <br /> ' 1 <br />