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UNIFIED PROGRAM CONSOLIDATED PTORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page persite) <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT CHANGE OF INFORMATION(Specify change- r T PERMANENTLY CLOSED SITE <br /> (Check one item only) local use only) r 8.TANK REMOVED 400 <br /> F 4.AMENDED PERMIT i` <br /> r 6.TEMPORARY SITE CLOSURE <br /> DSS 1.FACILITY/SITE INFORMATION <br /> BUSINESSNAME(Same as FACILITY or DBA-Doing Business As) 3 FACILI ID*, <br /> &3 q <br /> NEAREST C S REET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> CORPORATION r 5. COUNTY AGENCY` <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM COMMERCIAL r 2. INDIVIDUAL <br /> F 6. STATE AGENCY' <br /> I 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 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trusllands? - division,section or office which operates the LIST. <br /> �/ (This is the contact person for the tank records.) <br /> 404 r Yes Y'� 405 406 <br /> 11 PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 v - P NE 408 <br /> C SS �M <br /> MAILING)bTREET ADDRESS Q - <br /> r' � r <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> © L C <br /> 'A <br /> PROPERTY <br /> PROPERTY OWNER TYPE.. r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> . CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERALAGENCY <br /> III'.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> S 0'1-yLt_• GG�QJ <br /> MAILING OR STREET ADDRESS - 416 <br /> CITY 417 STATE 418 ZIP CODE 419 - <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> 1. CORPORATION F 3. PARTNERSHIP h 5. COUNTY AGENCY h 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 ( Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT "X STATE FUND&CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> al not fications and mailin swill writ to the tank owner unless box 1 or 2 is checked. <br /> )ill A PPI IrA UT SIGNATI IRF <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br /> (0-7-q I W <br />