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UNIFto PROGRAM CONSOLIDATED FOR 53 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page persue) <br /> Page _ of _ <br /> TYPE OF ACTION (' L NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4.AMENDED PERMIT local use.,Y) r B.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> -'1 I.FACILITY I SITE INFORMATION <br /> B INESS Same as AGILITY NAME or DBA-Doing Business As) 3� FACILITY Ip is <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r4. LOCAL AGENCY/DISTRICT <br /> r i. CORPORATION r 5. COUNTY AGENCY' <br /> BUSINESS TYPE r L GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INOMDUAL r 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR r 4.PROCESSOR r 6 OTHER r 3. PARTNERSHIP r 7. FEOERALAGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is faculty on(Mian Reservation or 'R owner of UST is a o 14 agwW.name o1 su"m=of <br /> REMAINING AT SITE VustlanEa2 Clwsion,section or office which operates me UST. <br /> (This Is the contact Parson for the tank racoras.) <br /> 404 r Yes r No 405 406 <br /> 11. PROPERTY OWNER INFORMATION <br /> PpqERTY OWNER N 407 PHONE 406 <br /> MAIO <br /> LING OR STREET ADDR SS 1 409 <br /> CITY 410 STATE 411 LP CODE 412 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> r I. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TAN OWNER E 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 416 PCODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r S. STATE AGENCY 420 <br /> r 1 CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 Call(9 16)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 S. LETTER OF CREDIT r S. STATE FUND&CFO LETTER r 99. OTHER: <br /> - <br /> F 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to intlicela which adtlress should he uee!for legal rrooficatlons ano mailing. r 1 FACILITY r 2 PROPERTY OWNER r 3. TANK OWNER 423 <br /> al notnraticns ann mailin s will be sant in <br /> me tank owner ante box 1 or 2 is cheGeb. <br /> CertirK,ion: I cartify mal the Information proviceo herein is tWa aM accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(pnn0 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 426 1958 UPGRADE CERTIFICATE NUMBER(Forlacal use only) 429 <br /> PK a31 too(D <br />