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1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION I, 1.NEW SITE PERMIT F 3.RENEWAL PERMIT .CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> I1 4.AMENDED PERMIT Iotal use only) r 8.TANK REMOVED 400 w <br /> F 6 TEMPORARY SITE CLOSURE <br /> MOS C ggl jg- 1.FACILITY/SITE INFORMATION TM <br /> BUSINESS NAME(Same as FACILITY tv3E <br /> EAANAMY yAor DBA-Doing Business As) 3 FACILITYID� <br /> NCC..//�/�-,,REST C 0 S STREET• 49117 ILITY <br /> FAC !/10�WNER TYPE <br /> �[ I� 4. LOCAL AGENCY/DISTRICT' <br /> 'K CORPORATION r 5. COUNTYAGENCY- <br /> BUSINESS TYPE h 1.GAS STATION F 3.FARM COMMERCIAL F 2. INDIVIDUAL <br /> I' 6. STATE AGENCY' <br /> I 2.DISTRIBUTOR I 4.PROCESSOR F 6 OTHER F 3. PARTNERSHIP F 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKSIs facility on Indian Reservation or 'If 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 r Yes 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 ,1 _ P NE 408 <br /> r ss � � 8- <br /> MAILINGfOB4TREET ADDRESS 4jy / <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE, r, F 2. INDIVIDUAL F 4. LOCAL AGENCY I DISTRICT I` 6. STATE AGENCY 413 <br /> X, CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER�N+AMEE; 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE F 2. INDIVIDUAL I' 4. LOCAL AGENCY/DISTRICT I' 6. STATE AGENCY 420 <br /> 1. CORPORATION IF 3. PARTNERSHIP I` 5. COUNTY AGENCY h 7. FEDERAL AGENCY <br /> tTY(TK)HQ 4 1 4 1 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) F 1. SELF-INSURED I' 4. SURETY BOND I� 7. STATE FUND I- 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE I- 5. LETTER OF CREDIT "XSTATE FUND&CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE r 6. EXEMPTION F 9. STATE FUND&CD 422 <br /> cate which address should be used for legal not cations and mailing. I' 1. FACILITY 2. PROPERTY OWNER 13. TANK OWNER 423 <br /> Cl,-Le al notifications and mailin swill be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: 1 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 /> PCF(1/99 revised) 5 <br /> U �� Formerly SWRCB Form A <br />