Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS /)1 /�7 <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_o <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(ss.as FAcu rry NAME or DBA- irg lam• As) 3, FACI000, L IT <br /> Y <br /> 2 4 e ID# 1. <br /> NEAREST CROSS STREET 401. FACILfi1 OWNER TYPE 4.LOCAL AGEN,*/DISTRICT- <br /> 1. <br /> II"' v ❑1.CORPORATION ❑5.COUNTY NCY* <br /> BUSINES AS STATION 3.FARM 5.COMMERCIAL 403• �2.INDIVIDUAL ❑6.STAT GENCY* <br /> TYPE ❑ DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FE RAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404• Is facility on Indian Reservation 405• •If owner of UST is a public agency: of supervisor of division,section or 406. <br /> REIING AT SITE or trust lands? office which operates the UST. (This is a contact person for the tank records.) <br /> ❑Yes AN, <br /> II. PROPERTY OWNER INFORMATION <br /> PROP�M OWNER AME 407 PHONE 408. <br /> v9 - - © '/s2- <br /> MAILING OR STREETS ` 409. <br /> EL !/ <br /> CITY STATE 411• ZIP CODE 412, <br /> 7-9 /-� 15,337 <br /> PROPERTY OWNER TYPE 1.CORPORATION 15,2. <br /> .P D UAL 4 ALA NCY/DISTRICT 6.STATE AGENCY 413• <br /> TNERSHIP 5.CO AGENCY ❑7.FEDERAL AGENCY <br /> II ANK OWN INFO ATION <br /> TANK OWNER.. E <br /> ala. PHONE als. <br /> 1761- 3 F <br /> 717 <br /> MAILING OR STREET ADDU S 416. <br /> -Z Li C )W j"I <br /> CITY a 7. T E � als. ZIP C DE 2 � 419. <br /> TANK OWNER TYPE ❑1.CORPORATIONINDIV AL �-4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> El 3.P RSHIP 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF FXUALIt""N UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 Call 916 322-9669 if questions arise 421. <br /> Y/PET42#VM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INS D ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARAI TEE [15.LETTER OF CREDIT /W.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSU CE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which addrqds should be used for legal notifications and mailing. <br /> Legal notifications and mailings wr sem to the tank owner unless box 1 or 2 is checked I.FACILITY [12. PROPERTY OWNER V}.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that)4 information provided here' is true and accurate to the best of my knowledge. <br /> SIGNATURE OF LIC DATE 424. PHONE 425• <br /> IC., /23o -7 [7tI l-R <br /> NAMP6rAMWANT(pnnt) 1 426• TITLE OF APPLICANT 427• <br /> STATE UST FACILITY NUMBER(Agmcyuseody) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agencyuse only) a29. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidGcs.org Rev.02/16/00 <br />