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UNIFIED PROGRAM CONSOLIDATED Fok <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 5.CHANGE OF INFORMA71 N(S ci/y change- F 7.PERMANENTLY CLO <br /> (Check one item only) local use only) F 8.TANK REMO 1 \ <br /> F 4.AMENDED PERMIT r%� <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSIN AME(Same as FACILI NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> T[ I <br /> VL <br /> L v <br /> TMIIHII <br /> N S CROSS STREET 401 / FA OWNER TYPE F 4, LOCAL AGENCY/DISTRICT• <br /> 1. CORPORATION r 5. COUNTY AGENCY' <br /> B I SS TYPE 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL F 6. STATE AGENCY- <br /> r 2.DISTRIBUTOR F 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP F 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 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 /> II.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 F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> F 1. CORPORATION F 3. PARTNERSHIP r 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> III.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 F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> F 1. CORPORATION r 3. PARTNERSHIP F S. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> 1,, <br /> TY(TK)HQ 4 1 4 1 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) r 1. SELF-INSURED F 4. SURETY BOND r 7. STATE FUND F 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE F 5. LETTER OF CREDIT F 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 which address should be used for legal notifications and mailing. F 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Le al not fcat ons and ma= <br /> swill be ent to the tank owner unless box 1 or 2 is checked. <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(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 429 <br /> c <br /> UPCF(1/99 revised) <br /> 1 5 Formerly SWRCB Form A <br /> ,L' <br />