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UNIFIED PROGRAM CONSOLIDATED FON... <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION F 1.NEW SITE PERMIT F 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION(Specify change- F 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) F 4.AMENDED PERMIT ly local use only) F 8.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE Ell <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> R� O �1(JVO <br /> NEAREST CROSS S__TREET 401 FACILITY OWNER TYPE I' 4, LOCAL AGENCY/DISTRICT' <br /> :rJ JC C. "u'(5� 1. CORPORATION I' 5. COUNTYAGENCY' <br /> BUSINESS TYPE 1.GAS STATION F 3.FARM F 5.COMMERCIAL 2. INDIVIDUAL F 6, STATE AGENCY- <br /> 2.DISTRIBUTOR F 4.PROCESSOR F 6.OTHER r 3. PARTNERSHIP I 7 FEDERAL AGENCY' 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 No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408 <br /> MAILING OR ST ADDRESS 409 <br /> 043 (2 3 1 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE rL�,)f F 2. INDIVIDUAL h 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> IF CORPORATION F 3. PARTNERSHIP I' 5. COUNTY AGENCY h 7. FEDERAL AGENCY <br /> //�` III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414PHONE 415 <br /> RLQ ?& S <br /> MAILING TREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE F 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> 1-1 CORPORATION I 3. PARTNERSHIP F 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 G C V Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) 1. SELF-INSURED F 4. SURETY BOND r 7. STATE FUND I' 10. LOCAL GOV=T MECHANISM <br /> 2. GUARANTEE r 5. LETTER OF CREDIT F 8. STATE FUND&CFO LETTER h 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> FCI.e7l.n.box to indicate which address should be used for legal not cations and mailing. F 1. FACILITY F 2. PROPERTYOWNER F 3. TANKOWNER 423 <br /> ications and mailin swill be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: ce ify t t the int -tion pr ided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE O PLICA T DATE _ �; 424 P/-f/'�'7 �.� 425 <br /> NAME OF APPLICA //l�L 426 TITLE OF APP I T 427 <br /> STATE UST FACILITY NUMBER(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 0 I �r� 5 Formerly SWRCB Form <br />