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a <br />I LIFTED PROGRAM CONSOIJDATF.D FORNTW <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page _ of _ <br />TYPE OF ACTION 0 1. NEW SITE PERMIT u 3. RENEWAL PERMIT ❑ 5.CHANGE OF INFORMAI-ION ❑ 7.PERMANENTLY CLOSED SITE <br />Check one nem onivt MENDED PERMIT pecify change local use only ❑ 8. TANK REMOVED <br />i <br />❑ &TEMPORARY SITE CLOSURE 4, <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business Asl s <br />FACILITY ID# <br />y <br />I <br />NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE 4. LOCAL AGENCY/DISTRICT' <br />,® <br />❑ 1. CORPORATION ❑ 5. COUNTY AGENCY' <br />BUSINESS 1. GAS STATION 0 3. FARM 5. COMMERCIAL <br />3 2. INDIVIDUAL ❑ 6. STATE AGENCY' <br />TYPE ❑ 2. DISTRIBUTOR C34. PROCESSOR C36. OTHER 403 <br />. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br />TOTAL NUMBER OF TANKS Is facility on Indian Reservation or <br />*If owner of UST is a public agency: name of supervisor of iivision. section or office which <br />REMAINING AT SITE I trusdands? <br />operates the UST ('ibis is the contact person for the tank records.) <br />4ot p Yes VNo 405 <br />1 406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME <br />NE 406 <br />PHO�y --'') <br />MAILING OR STREET ADDRESS 404 <br />ITY 410 1 <br />412 <br />STATE 41. ZIP CODE9,,,.g <br />PROPERTY OWNER TYPE E I. CORPORATION 0 2. INDIVIDUAL n 4. LOCAL AGENCY / DISTRICT C3 6. STATE AGENCY <br />3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 4U <br />MAILING OR STREET ADDRESS 414 <br />CITY 417 <br />STATE =CODE <br />419 <br />TANK OWNER TYPE I. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY / DISTRICT 0 6. STATE AGENCY 420 <br />3. PARTNERSHIP n 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 ! I1 1 Call (916) 322-9669 if questions arise 421 <br />I <br />1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ❑ I. SELF-INSURED ❑ 4. SURETY BOND 7, STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />j ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT C3 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />- VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one Dox to utaicate which address snowd be used for iegai notifications and mailing. <br />j Legal notifications and mailings will be sen: to the tank owner unless box I or 2 is checked. [3I. FACILITY PROPERTt' O WNER C3 3. TANK OWNER 423 <br />VII. APPLICANT SIGNATURE j <br />Certification - I certtfv that the information, ❑roviued herein :s true and accurate to the best of my knowledge. I <br />UPCF (1.'99 revised) 8 Formeriv SWRCB Form A <br />