Laserfiche WebLink
1 <br /> • UNI IED PROGRAM CONSOLIDATED FO M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION !�NEW SITE PERMIT I 3.RENEWAL PERMIT I 5.CHANGE OF INFORMATION(Specify change- I T PERMANENTLY CLOSED SITE <br /> (Check one item only) 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> I <br /> IF 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Bysiness As) 3 FACILITY ID M <br /> S 0 /;Ool LJ <br /> NEAREST CROS S REET 401 FACILITY OWNER TYPE I 4. LOCAL AGENCY/DISTRICT' <br /> I 1. CORPORATION I 5. COUNTYAGENCY' <br /> BUSINESS TYPE X1 GAS STATION r 3.FARM I 5.COMMERCIAL WC2. INDIVIDUAL <br /> I' 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'tf 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 I Yes I No 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME07 PHONE 408 <br /> 711115- 2© <br /> MAILING OR STREET ADDRESS 409 <br /> 79 Wciv <br /> CITY 410 <br /> STATE 411ZIP CODE 412. <br /> C 0I <br /> PROPERTY OWNER TYPE INDIVIDUAL I' 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> I 1. CORPORATION I 3. PARTNERSHIP I 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> "11�J1 S ` 4IL .3 - 220 <br /> MAILING OR STREET ADDRESS 1 416 <br /> CITY 417STATE 418 ZIP CODE 419 <br /> 1 <br /> TANK OWNER TYPE 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT h 6. STATE AGENCY 420 <br /> I 1. CORPORATION h 3. PARTNERSHIP I 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) I' 1. SELF-INSURED I,4. SURETY BOND STATE FUND 110. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE F 5. LETTER OF CREDIT I' 8. STATE FUND&CFO LETTER I' 99. OTHER. <br /> I 3. INSURANCE r 6. EXEMPTION F 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. I' 1. FACILITY F 2. PROPERTY OWNER h 3. TANK OWNER 423 <br /> Le al noldications and mailin swill be sent to the tank 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 PPLICA DATE OtM �� 424 P N 425 <br /> 100 <br /> NAME OF APP 1 ANT(print) 426 TITL APPVCANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 19,311 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> r�D 4* oa <br /> UPCF(1/99 revised) 5 T l D 1�3SC� Formerly SWRCB Form A <br /> • jz:r0 �3 <br /> U-1 /� <br />