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UNIFIED PROGRAM CONSOLIO EO FORM CC\ mZ <br /> TANK; <br /> UNDERGROUND STORAGE TANKS - FACILI <br /> I r f <br /> T�P_OF ACTION r I.NEW SITE PERMIT r 3.RENEWAL?ERMIT r S.C:-ANGE OF INFORMA..CN fSoeC:jelange. 7.PERMANENTLY CLOS'=]StT, <br /> (CTeclt one item oNy) oear u-e only) <br /> r a AMENDED PER.MR r d.TANK REMGVEO 100 <br /> • [-�,'_mPCRARY SITE CLCSURE <br /> 1.FACIUTY!SITE INFORMATION <br /> I BUSINESS NAME t arae as FACILITY NAME ar08A-Octng Business As) 3 FAC.L 0= <br /> Geo;- �� •F�r-aka✓,Z� w.��r. � � ��' I�������.��� 'D� � � � � <br /> NEAREST CR SS <br /> STREET 401 rAGILITY OWNER TYPE L [ a. LCCALAGcNCY/CIS�,CT' <br /> �rt, I/)N� �„CRPOAATION t`p�/ptJrwQi(IL� <br /> r( 3. COUTAGENCY' <br /> IVBUSINESS TYPE GAS STATION r 3.FARM i.COMMERCIAL r 7- :NOOUAI <br /> �i. STATE AGcYCY- <br /> ?ROCESSOP .O ER T. F= - CzOISTRIBUTOR r PARTNERSHIP <br /> 403 <br /> TOTAL NUM8ER OF TANKS ,s faeuty on mann Reservawn or *1.ner of US• s a=uctC agener.name asucermer at <br /> L <br /> REMAINING AT SITE I r4sur437 zNLw seocn or—.6=`•'nicn acerates me UST. <br /> (Ttuy,3 To cont=7ersw tar me tarot mcu=.) <br /> 404 z r Yes 405 406 <br /> 11.PROPERTY OWNE'R INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 4u <br /> MAILING OR STREET AOORESS <br /> Lc <br /> CIT`! 410 STATE 11 t ZIP(;DOE 412 <br /> < �k I `?syk� <br /> P9CPERTY OWNER TYPE —1 r 2. ,NOIVIOUAL r 4. _OcAI AGENCY/OISTR:CT r i. STA—..AGENCY 413 <br /> CO PORATICN o FE,-EaAL AGENCY <br /> r 3. PARTNERSHIP r COUNTY AGENCY r % <br /> Ill.TANK OWNER INFORMATION <br /> �A:IK OWNERNAME 414 - I ?HONE 415 <br /> Aih f(c �/ ►1lG1�'/ �� _33�-ion <br /> NAiL:NG OR STREET ADDRESS 416 <br /> Li <br /> C r 411 I STATE -1a ' ZIP CODE 419 <br /> c! `t J <br /> TANK OWNER TYPE �� [- Z. iNOMOUAI r 4. LOCALAGZNCY l OISTRICT r i. STATE AGENCY 120 <br /> r I. CO --PORATI r 3. PARTNERSHIP r i. COUNTY 4Gc"ICY r '. FEOE.RAL AGENCY <br /> ccc r• <br /> i! TK)HQ 14 14 I I I ( I ( Call(916)322-9669 4 questions anse <br /> ( I 1 v c t <br /> rry <br /> 1NOICATE METHOO(S) r t0. LOCAL GOVT MEC 4ANIShI <br /> r t. SELF-INSURED r 4. SURETY 80N0 T. c <br /> r 2 GUARANTEE r s. LETTER OF CREDIT 3. STATE FUNO a CFO LcTcR r 99. OTHER= <br /> r 3. INSURANCE r.3. O(EMPTION r 9. STATE FUND a CO <br /> c <br /> C..,jg' one WX to rtdicate wroC1 aacre3s srouid oe used for*gal nottf atms and matiinq. [' t. FACIUTY r 2. PROPERTY OWNER r 3. TANK OWNER <br /> t-sat nofftatroms and matiitWs w II oe sertt o me tarot comer untess eoz I or 7 a Cletltrt <br /> Inf SPOI 1rAm r Cer."ATIIRF <br /> Cendtcatj0rr 1 C@Mty mat the efct auen cewcad neretn is cue and ats:ume to the oast Of my knowteoqe. <br /> SIGNATURE OF APPLICANT i ]A /o-1�r ata I ?xtO�NF� <br /> NAME OF APP nr) L �` 4251 -.LE OF APPUCANT 427 <br /> STATE UST FACILITY NUMBER(Far roof use onv) 4251 ld UPGRADE CrRT F•CATE NUMBER lrcraocar sse snly) 429 <br /> O . y � <br /> 'k <br /> ,t <br />