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U NOE OGRAM CONSOLIDATED FM <br /> w <br /> � t TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page perAde <br /> Page _ � _ <br /> TYPE OF ACTION j' 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r S.CHANGE OF INFORMATION(Spedy,change- r 7.PERMANENTLY SED SITE <br /> (Check one item only) r 4.AMENDED PERMIT local use only) r 8.TANK REMO 4 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY!SITE INFORMATION <br /> BUSINESS NAME(S a as FlikCILITY <br /> DAME or OBA-Doing ztBusine 3 FACILITY 10# <br /> 0°✓ L <br /> NEAREST C S ST T FACILITY OWNER TYPE r 4. LOCAL AGENCYIDISTRICT- <br /> r 1. CORPORATION r 5. COUNTY AGENCY- <br /> BUSINES PE 1.GAS STATION r®3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 6. STATE AGENCY' <br /> 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 .lands? divisiom section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 r Yes r No 405 4f16 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> F 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> 111 TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <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 /> r CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> tTYT�K)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 /> r 2. GUARANTEE r 5. LETTER OF CREDIT r 8. 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 wh ch address should be used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> 1 notAica ions and mailin wi11 be sent to the tank owner unless x 1 or 2 is checked <br /> VII A12121 ICANT 91_bIATI 109: <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 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 />