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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANKS - FACILITY <br />TANKS <br />(one page per site) <br />Page _ of _ <br />TYPE OF ACTION, NEW SITE PERMIT r 3. RENEWAL PERMIT r 5. CHANGE OF INFORMATION (Specify change - r 7. PERMANENTLY CLOSED SITE <br />(Check one item only) jv/ F 4. AMENDED PERMIT local use on r 8. TANK REMOVED 400 <br />r 6. TEMPORARY SITE CLOSURE <br />I. FACILITY / SITE INFORMATION <br />84 NESS NAME (Same as FACILITY NAM or OBA - Doing Business As) 3 / <br />FACILITY 10 x <br />/ Ec <br />NEAREST CROSS STR T' 1 <br />FACILITY OWNER TYPE <br />r <br />F 4, LOCAL AGENCY/DISTRICT' <br />1. CORPORATION <br />r 2. INDIVIDUAL <br />r 5. COUNTY AGENCY - <br />(' 6. STATE AGENCY - <br />BUSINESS TYPE r 1. GAS STATION r 3. FARM r 5. COMMERCIAL <br />r 2. DISTRIBUTOR r 4. PROCESSOR OTHER <br />V ` PARTNERSHIP <br />F 7. FEDERAL AGENCY- 402 <br />403 <br />TOTAL NUMBER OF TANKS <br />REMAINING AT SITE <br />Is facility on Indian Reservation or 'If owner of UST is a cuolic agency: name of supervisor of <br />trustlands? division, section or office which operates the UST. <br />(This is the contact person for the tank records.) �- <br />406 <br />404 <br />F YesNo 405 <br />II. PROPERTY OWNER INFORMATION <br />PROPPqY OWNER NAME 407 <br />CI /M <br />PHONE 408 <br />MAILING OR STREET ADDRESS 409 <br />/ 10 SO4 0 <br />STATE 411 <br />CITY 410 <br />C <br />ZIP CODE 412 <br />�� �O <br />PROPERTY OWNER TYPE F 2. INDIVIDUAL r 4. LOCAL AGENCY t DISTRICT <br />r 5. STATE AGENCY 413 <br />r 1. CORPORATION PARTNERSHIP r 5. COUNTY AGENCY <br />F 7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAM 414C <br />5elf <br />PHONE 415 <br />2 ® <br />MAILING OR T T/ADD ESS 416 s' <br />STATE 418 <br />CITY 4,7 <br />ZIP CODE 419 <br />. <br />TANK OWNER TYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY / DISTRICT <br />r 6. STATE AGENCY 420 <br />F 1. CORPORATION Cj;< PARTNERSHIP r 5. COUNTY AGENCY <br />r 7. FEDERAL AGENCY <br />TY (TK) HQ 4 4 Call (916) 322-9669 if questions arise <br />421 <br />INDICATE METHOD(S) F 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND <br />F 10. LOCAL GOV=T MECHANISM <br />r 2. GUARANTEE r S. LETTER OF CREDIT r 8. STATE FUND & CFO LETTER <br />F 99. OTHER: <br />422 <br />�3. INSURANCE F 6. EXEMPTION r 9. STATE FUND & CD <br />Check one box to indicate which address should be used for legal notifications and mailing. F 1. FACILITY . ROPERTY OWNER r 3. TANK OWNER 423 <br />Legal notifications and marlin s will be sent to the tank owner unless box 1 or 2 is checked. <br />Certification: I certify that the formation rovided herein is tru and accurate to the best of my knowledge. <br />424 <br />- 425 <br />PHONE <br />SIGNATURE OF APPLICANT <br />DATE JJ -� rA _ <br />47 `• J DO <br />/ J / <br />NAME OF APPLICANT (print)/ a / 426 <br />TITLE OF APPLICANT 427 <br />STATE UST FACILITY NUMBER (Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 <br />