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Ila <br /> UOIED PROGRAM CONSOLIDATED ORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION j' I.NEW SITE PERMIT r 3.RENEWAL PERMIT girel"GE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SYTE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID% <br /> _C�l�ser-- 3zz�eZ <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> F 1. CORPORATION r 5. COUNTYAGENCY' <br /> BUSINESS TYPE F 1.GAS STATION F 3.FARM r 5.COMfAERCAL r 2. INDIVIDUAL F 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r S.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation of 'H owner N UST a a puolic agency:name of supe =f of <br /> REMAINING AT SITE twtlands? division,section or atfice which operates me UST. <br /> (This is me contact person for me tank records.) <br /> 404 ryes F No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 TATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE r 2. INDNIDUAL F 4. LOCAL AGENCY I DISTRICT F 6. STATEAGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP F 5. COUNTYAGENCY F 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 LP OOE 419 <br /> TANK OWNER TYPE F 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT F 6. STATEAGENCY 420 <br /> F 1. CORPORATION r 3. PARTNERSHIP C 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) 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 a. STATE FUND B CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9.STATE FUND a CD 422 <br /> Check one box to indicate which address shouts be used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTY OWNER F 3. TANK OWNER 423 <br /> Legal notircalions and mailings will be sent t0 me tank owner imless box 1 of is Checked. <br /> Cenlrxation: I certify mat the information provided herein is We and..rate to me best of my knowlabge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(pnn') 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fwlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forloca/use only) 422 <br />