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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page r site) <br /> Pageof <br /> TYPE OF ACTION F 1.NEW SITE PERMIT F 3.RENEWAL PERMIT r CHANGE OF INFORMATION(Specify change- F7.PERMANENTLY C OSED SIT <br /> (Check one item only) local use only) r 8.TANK REMOVED 400 <br /> r 4.AMENDED PERMIT lGri <br /> F' 6 TEMPORARY SITE CLOSURE ` <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS-NAME(Same as FACILITY NAME o BA- oing Business As) 3 FACILITY ID# Q <br /> NEAREST CROUS S BEET 401 FACILITY OWNER TYPE F 4. LOCAL AGENCY/DISTRICT• <br /> FV 1/CORPORATION r' 5. COUNTYAGENCY- <br /> BUSINESS TYPE Fri,GAS STATION F 3.FARM F 5.COMMERCIAL ,H-'/2. INDIVIDUAL r 6 STATE AGENCY' <br /> F 2.DISTRIBUTOR F 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP F 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian;Nso <br /> e lion or 'If owner of UST is a public agency.name of supervisor of <br /> REMAINING AT SITE / trustlands? division,section or office which operates the UST. <br /> IJ/ (This is the contact person for the tank records.) <br /> 404 F,Yes 405 406 <br /> 11.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 r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT F 6, STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> III.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 r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION F' 3. PARTNERSHIP F 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) I 1. SELF-INSURED r 4 SURETY BOND r 7. STATE FUND F 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE F 5. LETTER OF CREDIT r B. STATE FUND&CFO LETTER F 99. OTHER: <br /> r 3. INSURANCE I 6. EXEMPTION r 9, STATE FUND&CID <br /> 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Le al notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification. I certify that the information provided herein is true and accurate to the best 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 rr NUMBE R(For local use onnl�y)/ 4211 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) <br /> 5 Formerly SWRCB Form A <br />