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7F� <br /> f-- UNIFIED PROGRAM CONSOLIDATED FORM MAR Q 5 2002 \ <br /> F,+ 137P ENVIRONMENT HEA. iJ NK� �pv <br /> UNDERGROUND STORAGE TANKS - FACILI�kRMIT/SEFvI`1F _ pny�(a <br /> 2 os/8 a 56 (one pa�Cper site <br /> Page _ of _ <br /> TYPE OF ACTION r- 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Speafy charge- r'7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4.AMENDED PERMIT local use only) r- S.TANK REMOVED 400 '\G <br /> C 6,TEMPORARY SITE CLOSURE ^ <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Doing Business As) 3 FACILITY ID 3 //II <br /> NEARE TCROS REET� 1 FACILITY OWNER TYPE #4. LOCAL GENCY/DIESTRICT' •I,r ,. CORPORATION . Y AGENCY' <br /> BUSINESS TYPE r 1,GAS STATION 1K3.FARM r S.COMMERCIAL 1 2. INDIVIDUAL r 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR T- 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP F 7. FEDERAL AGENCY- 402' <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility nn lno an Raservetbn nr 'If o77r of UST is a comic agency:name a of <br /> REMAINING AT SITE trustlands4 I division,section or alfice whirls operates the UST.(This is we mnol parson for the tank hi <br /> Yes <br /> 404 r- rNo 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY O ER NAME 4 PHONE 408 <br /> MAILING OR STREET AD 6 409 <br /> S' 14 S E 411 ZIP CODE 412 <br /> CITY 410 <br /> P P_RTY OWNER TYPE , INDIVIDUAL r 4. LOCAL AGENCY I DISTRI r' 6, STATEAGENCY 413 <br /> r_ 1, CORPORATION C l PARTNERSHIP [' 5. COUNTYAGENCY r- 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MILIG ADDRESS 416 <br /> cm 4n <br /> STATE a18 ZIP CODE a19 <br /> rN_KOWNERTYPE [- . INDIVIDUAL )- 4. LOCAL AGENCY/DISTRICT C 6. STATE AGENCY 420 <br /> I 1. CORPORATION r 7 PARTNERSHIP C 5, COUNTY AGENCY T 7. FEDERAL AGENCY <br /> TY(TK)HO 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOO(S) r 1. SELF-INSURED T 4. SURETY BOND r 7. STATE FUND F 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r- 5. LETTER OF CREDIT r a. STATE FUND S CFO LETTER r 99. OTHER: <br /> - <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND B CD 422 <br /> Chock one box to intlicato which address sir l be used for legal notlwooruu end mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> al notd tions and marlin swill t»sent to the tank owner unless box I or 2 is cnedtetl. <br /> CeMwtion: I comfy that the information provided herein is true d accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE / 424 PHO E _ 425 <br /> D,2 d - <br /> NAME OF APPLICANT(pont) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 425 1990 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />