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it UNIFIED PROGRAM CONSOLIDATED FORM <br /> MAR 0 5 2002 \� <br /> F,- 13 737 ENVIRONMENT HEA TJANK�i <br /> rRMIT/SERVISEo <br /> I <br /> UNDERGROUNDSTOP2oETAaSS - FAclLl (one page per site <br /> Page _ of _ <br /> r I. r 3.RENEWAL PERMIT )- s.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> TYPE OFACTION 1NEW SITE PERMIT I. 8.TANK REMOVED 400 r <br /> (Check one item only) r 4,AMENDED PERMIT pWonly) �\D <br /> T 6.TEMPORARY SITE CLOSURE <br /> /I I.FACILITY 1 SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY lD a <br /> FACILITY OWNER TYPE 1 4. LOCAL AGENCYIOISTRICT' 3 <br /> NEARE TCROS REET� 1 [- 1. CORPORATION I- 5. COUNTY AGENCY- v <br /> BUSINE S TYPE ,,,11Tyyy L-2. INCMDUAL 16. STATE AGENCY' <br /> r 1.GAS STATION f 3.FARM T 5.COMMERCIAL C 3 PARTNERSHIP r 1. FEDERAL AGENCY' 402 <br /> T 2 DISTRIBUTOR 4.PROCESSOR T 6.OT14ER THER <br /> TOTAL NUMBER OF TANKS Is famliry nn Ineian Reservetion of -if m. r.fs fUS?'IX office wntlt^o� es the UST. sof pf <br /> trustlanOs7 division, <br /> REMAINING AT SITE I (This is Ne contact Pelson far Ne Iankc rds) <br /> 404 1 Yes ! No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PHONE 408 <br /> PROPERTY O ERNAME 4 7 <br /> MAILINGOR TREETAD S 408 <br /> S E 411 ZIP OD 412 r <br /> CITY 410 <br /> 6. STATEAGENCY <br /> PR P_RTY OWNER TYPE INDIVIDUAL <br /> [- 4, LOCAL AGENCYIDISTRI i' 7. FEDERALAGENCY413 <br /> I' 1. CORPORATION IF 3 PARTNERSHIP r 5. COUNTY AGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> TANK OWNER NAME 414 <br /> MAILING OR STREET AD DRESS 416 <br /> STATE 418 ZIP CODE 419 <br /> CITY 417 <br /> AGENCY <br /> TANK OWNER TYPE I- . INOMDUAL <br /> 14. LOCAGENCYIDISTRICT 20 <br /> AL r 7. FEDERALAGENCY <br /> I- 1. CORPORATION [- 0, PARTNERSHIP C S. COUNTY AGENCY <br /> 421 <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise <br /> [-7. STATE FUND 10. LOCAL GOV=T MECHANISM <br /> INDICATE METHOO(S) r 1. SELF-INSURED r 4. SURETYBOND <br /> C <br /> r d. STATE FUNDSCFO LETTER r 99. OTHER: 422 <br /> r 2. GUARANTEE r S. LETTER OF CREDIT r 9. STATE FUND 8 CO <br /> r 3. INSURANCE C 6. EXEMPTION <br /> Check one box n land mawhich address i le M t used for legal ith- sS box Bons and mailing. r 1. FACILITY <br /> I 2. PROPERTY OWNER C 3. TANK OWNER 423 <br /> al notl(G'li n5 and marlin s will0e senile Meta ownef VnIe55 box 1 pf is UIefY.ed. <br /> Ce.,foalion: I cendy that the information provided herein is W e accurate to this best of my MuwWge.GATE 424 PHO E 425 <br /> .�j / <br /> SIGNATURE Of APPLICANT a� O e <br /> 426 TITLEOFAPPUCANT 427 <br /> NAME OF APPLICANT(pan() <br /> STATEUSTFACILITY NUMBER(For bcr use Only) <br /> 428 1996 UPGRADE CERTIFICATE NUMBER(FOrlocal use only) 429 <br />