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a Is <br /> MWIED PROGRAM CONSOLIDATED FORMW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACIL=NAME or DBA-Doing BusinessZ) 3. FACILITY <br /> ITO t. <br /> United Parcel Service,Inc. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> Waterloo El 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS❑ 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403- ❑2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ®6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 405. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 1 ❑Yes ❑No Herman Meyer <br /> IL .PROPERTY OWNER INFORMATION. <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> United Parcel Service,Inc. 916-3734005 <br /> MAILING OR STREET ADDRESS 409. <br /> 1380 Shore Street <br /> CITY 410 STATE 411. ZIP CODE 412. <br /> West Sacramento CA 95691 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATIQN <br /> TANK OWNER NAME 414, PHONE 415, <br /> United Parcel Service,Inc. 916-373-4005 <br /> MAILING OR STREET ADDRESS 416• <br /> 1380 Shore Street <br /> CITY 417. STATE 418. ZIP CODE 419, <br /> West Sacramento CA 95691 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> W. BOARD OF EQUAI;IZATIQN YJS� STORAGE F7EE ACCOIJNT N tjM�3ER <br /> TY(TK)HQ 44- Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM LIST FINANCIAL RESPONSIBIIdTY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOV'T MECHANISM 422. <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.AP'LICANT SIGNATURE <br /> Certification: 1 certify that the information provided here'm is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT _ DATE424. PHONE 425. <br /> t Z 03; <br /> j 916-373-7250 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427. <br /> Steven F.Carter Distnet Plant Engineering Manager <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />