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UNI- D PROGRAM CONSOLIDATED F 0 <br /> M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY i <br /> (one page per <br /> Page _ _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY SED SITE ,1 <br /> (Check one item only) use <br /> F a.AMENDED PERMIT local only) r 8.TANK REMOV 400 / <br /> !( <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sjfne as FACILITY ME or DBA-Doing Busines ;33 g^ FACILITY ID# <br /> 71 /// V`� L <br /> NEAREST C SST T FACILITY OWNER TYPE r 4. LOCAL AGENCY/OtSTRICT- <br /> r 1. CORPORATION r 5. COUNTY AGENCY• <br /> BUSINES PE1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL r 5. STATE AGENCY• <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 5.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 puolic 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 r No 405 406 <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. iNOfVIOUAL r 4. LOCAL AGENCY I DISTRICT r 5. 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 S. STATE AGENCY 420 <br /> r 1 CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> 111 BOARD DE EQ1 fill 17ATION I IST STORAGE EEE ACC-01 INT NUMBER - <br /> I <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 /> r 2. GUARANTEE r 5. LETTER OF CREDIT r a. STATE FUND&CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Chedt one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY r 2- PROPERTY OWNER r 3. TANK OWNER 423 <br /> al notfi.lions <br /> an mailin swill be sent to the tank owner unless box 1 or 2 is checked. <br /> 11111 AD0111CANTSIGNATURE <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(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> 0 -74 <br /> i <br />