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UNI IED PROGRAM CONSOLIDATED IF M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per sire) <br /> T4 <br /> Page _ o/ _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT T4-CHANGE OF INFORMATION(Specity change- r 7.PERMANENTLY CLOSED SIT <br /> (Check one item only) T /� <br /> F 4.AMENDED PERMIT local use only) I(L19 L hU M�D✓ r B.TANK REMOVED 400 <br /> y� r 6.TEMPORARY SITE CLOSURE <br /> f�ay V&411110 I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or OB Doing Bus' se As) 3 F.ABIhRY ID# <br /> � �� Ply- <br /> NEARESTCROSS STREET 401 FACILITY OWNER TYPE <br /> F 4 LOCAL AGENCY/DISTRICT• <br /> F 1. CORPORATION F S. COUNTY AGENCY- <br /> BUSINESS TYPE r 1.GAS STATION F 3.FARM r 5.COMMERCIAL F 2. INDIVIDUAL <br /> F 2.DISTRIBUTOR F 4 PROCESSOR F 8 OTHER r 3 PARTNERSHIP r 6. STATE AGENCY' <br /> r 7. FEDERALAGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'if owner of UST is a public agency name W supervisor of <br /> REMAINING AT SITE trustlands7 division.section oro�oe which operates the UST. <br /> l (This is Ne contact parson for the tank records.) <br /> 409 r Yes F No 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> r 1. CORPORATION F 3. PARTNERSHIP r 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY I DISTRICT F 6. STATE AGENCY 420 <br /> F 1. CORPORATION F 3. PARTNERSHIP r 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) [' 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r a. STATE FUND 8 CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE r 6, EXEMPTION r 9. STATE FUND&CD 422 <br /> Check nine box to indicate whits address should be used for legal notincmt dmi and mailing. F 1. FACILITY r 2. PROPERTY OWNER F 3. TANK OWNER 423 <br /> Legal nordications and nailing <br /> ailin swill se tt thetank owner unless box t or is Checked. <br /> Certification: I certify that the inloonation provided herein is vue and accurate to Ne beat of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forloral use only) 429 <br /> UPCF(1/99 revised) 6 Formerly SWRCB Form A <br />