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� ! UNtOED PROGRAM CONSOLIDATED F <br /> AFS q 7(a <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of <br /> !PE OF ACTION r f.NEW SITE PERMIT I- 3.RENEWAL PERMIT r .C:�MIGE OF INFORMATION(Sp-y mange- r 7.PERMANENTLY CLOSED SITE <br /> Cbecx one item only) <br /> r a.AMENDED PERMIT ,oma"Se omY) r 8.TANK REMOVED 400 <br /> r o-. .EMPORARY SITE CLOSURE OL <br /> I.FACILITY/SITE INFORMATION <br /> 3USi S NAMS(Same as FAC,IµjY NAME or 0 -Oamg Busu�SS As), �L-v4" <br /> ACILITY j0+t <br /> l Uv'1{`7 / s, <br /> NEAREST CROSS STR T 4Ot I FACILITY OVfNER TYPE r a. LOCAL AGENCY/DISTRtCT- <br /> r 1. CORPORATION r 5. COUNTY AGENCY' <br /> 3USINESS TYPE 1.GAS STATIO9 r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> r s. STATE AGENCY- <br /> Z.DISTRIBUTOR r 4.PROCESSOR r S.OTHER r 3. PARTNERSHIP r <br /> r 7. FEDERAL AGENCY- adz <br /> 403 <br /> TOTAL NUMBER OF TANKS Is faairy on Indian Resenaoon or 7 owner at UST s a oucic ager/:name of suosrwsor of <br /> REMAINING AT SITE rrusdands? 31v1310n.wear*or office whch operates,me UST. <br /> (This is me cantaa person fat me tarot r9oarcL) <br /> Q4 r Yes r Nd Ops 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CI 410 I STATE 411 ZIPCODE 412 <br /> PROPERTY OWNER TYPE ( L INOIVIOUAL r 4. LOCAL AGENCY i DISTRICT r 3. STATE AGENCY 413 <br /> r 1. CORPORATION ( 3. PARTNERSHIP r 5. COUNTY AGENCY r 7 FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 I <br /> MAILING OR STREET ADDRESS 416 <br /> I <br /> !T+ 417 STATE 418 ZIP CODE 419 i <br /> TANK OWNER TYPE I- L 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 /> 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 S. STATE FUND&CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD Ori j <br /> Cheat one pox to indicate wrtich address would oe used for Iegal nc9diaatrons and mailing r I. FACILITY r L PROPERTY OWNER r 3. TANK OWNER 423 <br /> Lepel notificettons and mai inns will be sem to me tam*owner grilm pox 1 or 2 is cneaceo <br /> VII APPI IrAUT_S=MATI IRF: <br /> Certification: I candy that the information Provided herein Is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT I DATE 424 PHONE 425 i <br /> NAME OF APPLICANT(print) 4251 71TLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For localuse 428) '398 UPGRADE CERTIFICATE NUMBER(Far loan use only) 429 j <br /> � I i <br /> -/oi <br />