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UNIFIED PROGRAM CONSOLIDATED F M F_dD�O� p9� <br /> �( TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page of <br /> TYPE OF ACTION I 1.NEW SITE PERMIT I' 3.RENEWAL PERMIT 5.CHANGE OF INFORMATI N(S city change- I 7.PERMANENTLY CLO <br /> (Check one item only) �R �� r� <br /> I'4.AMENDED PERMIT local use only) �V N/N K/I . r 8.TANK REMO <br /> I 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION <br /> BUSIN AME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> 1 W1141 c <br /> -Z'Y907 .-. AO <br /> N S CROSS STREET 401 / FA90TY OWNER TYPE I 4. LOCAL AGENCY/DISTRICT"12, � <br /> U G\> 1. CORPORATION I' 5. COUNTYAGENCY" q <br /> BUSIRESS TYPE W1.GAS STATION I' 3.FARM I' 5.COMMERCIAL Y 2. INDIVIDUAL <br /> F 6. STATE AGENCY" <br /> I' 2.DISTRIBUTOR I 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY" 40 <br /> 403 V,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 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. INDIVIDUAL I'4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> IF 1. CORPORATION IF 3. PARTNERSHIP r 5. COUNTY AGENCY F 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 h 2. INDIVIDUAL I'4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> I 1. CORPORATION F 3. PARTNERSHIP I 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> QA RD OF FQI IAJI 17A1ION I IST STORAGE EFF ACCOI INT W1 WRIER <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) h 1. SELF-INSURED I'4. SURETY BOND P 7. STATE FUND IF 10. LOCAL GOV-T MECHANISM <br /> IF 2. GUARANTEE F 5. LETTER OF CREDIT I 8. STATE FUND&CFO LETTER I'99. OTHER: <br /> F 3. INSURANCE r 6. EXEMPTION I 9. STATE FUND&CD 422 <br /> �Cl.,ck one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY I'2. PROPERTY OWNER I 3. TANK OWNER 423 <br /> al notirica ions and maili will ent to the tank owner unless box 1 or 2 is chocked, <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(�' 5 <br /> 1/99 revised)) Formerly SWRCB Form A <br /> v <br /> 7/°o 0 <br />