Laserfiche WebLink
1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> \,�- Page _ of _ <br /> TYPE OF ACTION F 1.NEW SITE PERMIT r 3.RENEWAL PERMIT ][5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> r 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 (% <br /> I 6.TEMPORARY SITE CLOSURE 1/ <br /> CA LUUVv I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID if in <br /> IT <br /> NEAREST CROSS STRE T 401 1, FACILITY OWNER TYPE F 4. LOCAL AGENCY/DISTRICT` <br /> D F 1. CORPORATION IF 5. COUNTY AGENCY` <br /> BUSINESS TYPE F 1.GAS STATION F 3.FARM 5.COMMERCIAL r 2. INDIVIDUAL <br /> F 2.DISTRIBUTOR F 4.PROCESSOR I 6.OTHER F 3. PARTNERSHIP F 6. STATE AGENCY` <br /> I' 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 F Yes XNo 405 406 <br /> 11.PROPERTY OWNERINFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> e,L/Fale"'li9 )vs T . Sal///rte <br /> MAILING OR STREET ADDRESS 409 <br /> /SSS LV �� �/ �I'T �T , /oo <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> 7Oek7- +'V 1 C41 Z o 3 <br /> PROPERTY OWNER TYPE F 2. INDIVIDUAL I 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> 1. CORPORATION F 3. PARTNERSHIP I 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 I 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> I 1. CORPORATION F 3. PARTNERSHIP I 5. COUNTY AGENCY IF 7. FEDERAL AGENCY <br /> TY(TK)HQ F4T4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) F 1. SELF-INSURED I 4. SURETY BOND P 7. STATE FUND F 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT I 8. STATE FUND&CFO LETTER I 99. OTHER: <br /> F 3. INSURANCE F 6. EXEMPTION I 9. STATE FUND&CD 422 <br /> �Ch-eck one box to indicate which address should be used for legal notifications and mailing: I 1. FACILI I 2. PROPERTY OWNER I 3. TANK OWNER 423 <br /> al nolffi tions and mailin swill nt to th n r less 1 or i k <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 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(1/99 revised) ) C"t 5 Former) SWRCB Form A <br />