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UN FIED PROGRAM CONSOLIDATED -0 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site <br /> Page _ of _ <br /> TYPE OF ACTION I 1.NEW SITE PERMIT F 3.RENEWAL PERMIT 5.CHANGE OF INFFPM TION Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> F4.AMENDED PERMIT loos/use only) r 8.TANK REMOVED 400 <br /> IF 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION' <br /> BU E S NAME(Same as F CILITY NAME or DBA-Doing Business As) 3 FACILITY 10# <br /> s -If /.3� z�_ <br /> N T CROSS STREET 01 fry FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT• <br /> J5- I' 1. CORPORATION F 5. COUNTY AGENCY' <br /> BUSINESS TYPE 1.GAS STATION IF 3.FARM I 5.COMMERCIAL r 2. INDIVIDUAL <br /> r 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR IF 4.PROCESSOR F 6.OTHER r 3. PARTNERSHIP I' 7. FEDERALAGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is 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 r Yes r No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> PROPERTY OWNER TYPE I 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY I T FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE I 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION I 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> IV QARnnpF:QiIA117ATIONIISISIORAGF:F:I=FAr-rC)IINTbl'IMRPEt <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED P 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND&CFO LETTER I 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> E�ii <br /> box to indicate which address should be used for legal notifications and mailing. P 1. FACILITY r 2. PROPERTYOWNER r 3. TANK OWNER 423 <br /> ca ions and mailin s will b s, t nk owner unless box 1 or 2 is checked. <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER tFor local u only)_ 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> 5 9 a � G � Zoo� <br /> UPCF(1/99 revised) / Forme y RCB Form A <br /> r <br />