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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS <br /> (one page per site) <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specvey,charge- r 7.PERMANENTLY CLOSED SITE <br /> Page - Of <br /> (Check one item only) <br /> r 4.AMENDED PERMIT local dse only) r 8.TANK REMO ED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS,NAME(Same as FACILITY NAME or OBA-Doing Business�AsI) 3 FACILITY IDa <br /> NEAR ST CROSS STREET 90�/ Al, �� ,�y„ FACILITY OWNER TYPE r 4. LOCAL AGE Y/DISTRICT• <br /> ^!l CORPORATION <br /> BUSINESS TYPE r 1.GA$ TATION r 3.FARM .COMMERCIAL r 2. INDIVIDUAL r 5. COUNTYAG NCY• <br /> r 2.DISTRIBUTOR r 4 PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 6. STATE AGENCY' <br /> 403 r 7. FEDERAL AGENCY- 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •d owner of UST is a puolic agency:name of suaenasor of <br /> REMAINING AT SITE vustlands9 divtsbofficen,SI Cion or office which operates Ne UST. <br /> (This is Ne contact person for Na tank records.) <br /> 404 r Yea X. 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> L <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 $TATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AD ENCY 413 <br /> r 1. CORPORATION [ 3. PARTNERSHIP r 5 COUNTY AGENCY r 7. FEDERAL GENCY <br /> III.TANK OWNER INFORMATION <br /> TANK 0 ER NAME . 414 ' PHONE J15 <br /> (o ' <br /> MAILING OR STREET AOOARE,SS 41 <br /> X05 Lf 1103 <br /> 1113 <br /> CITY J17! / STAT 616 LP C0� 419O� <br /> TANK OWNER TYtPE� r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> CORPORATION F 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 J.4 1 Call(916)322-9669 it questions arise 421 <br /> INDICATE METHOO(S) [' 1. SELF-INSURED r 4. SURETY BOND STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT STATE FUND 8 CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 5. EXEMPTION ��` ///� STATE FUND a CO 422 <br /> Check ane box to indicate which address shcWd be used for legal noM¢ations and mailing, r 1. FACILITY r 2. PROPERTY OWNER r <br /> al notif tions a mailings will be sent o Ute lank Owner Vnle s W,1 Or 2 is rh"e, 7. TANK OWNER 423 <br /> Certr6cwton: 1 candy that Ne information provided herein Is ttue and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(poop 425 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For/owl use only) 428 1948 UP GRADE CERTIFICATE NUMBER(For local use only) 429 i <br />