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UNIFIED PROGRAM CONSOLIDATED FORM <br /> =r/7UNDERGROUND STORAGE TANKS - FACI <br /> Page _ of _ <br /> TYPE OF ACTION 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r S.CHANGE OF INFORMATION(Specify Mange- r Y.PERMANENTLY CLOSED SITE <br /> (Check ors item only) r 4.MENDED PEPERMITlocal use.*) r 6.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION c;4 INIZIr - <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID t <br /> ' icItrLC coaDoa4o ` 'J" <br /> Al <br /> N TCROSS ST ET 401 CII OVMERTYPE r 4. LOCAL AGENCY/DISTRICT• <br /> 7. CORPORATION DEC 14 2000 r 5. COUNTYAGENCr <br /> BUSINESS TYPE g'('1 GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3 PARTNERSHI p r 6. STATE AGENCY' <br /> €NVIRONMENT HEALT r 7. FEDERAL AGENCY• 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is lecifly on Indian Reservation a •d owrtar of UST is a public agency. f <br /> REMAINING AT SITE Nus6ust.? division,sectio,or off.ahlrh operates the UT. <br /> S <br /> 2 (This ie the mnlact person for B1e tank recosda) <br /> 404 -] rYes kNo 405 406 <br /> If.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE 40B <br /> L I,,? c6lix eCCA42 <br /> f(d�ILING OR STREET DRESS 40 <br /> V � Cr <br /> CITY atO <br /> C411 IP412 <br /> S/o �P�C <br /> PROPERTY OWNER TYPE. r 2. INONIDUAL r 4. LOCAL AGENCY I DISTRICT r S. STATEAGENCY 413 <br /> P/1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> c, r„�a LL - 30-344y <br /> MAILING OR STREET ADDRESS 416 <br /> ;y�S /�GI�IC V <br /> CITY 417 STATE 416 21P CODE 419 <br /> QC k, v N C l3oZc� <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATEAGENCY 420 <br /> Ix t. CORPORATION r 3. PARTNERSHIP r S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> IV RQARMnCVnIIA 117 A TION IMT STORAGE FFE ACCOUNT NUMBER <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METH00(S) ]' 1. SELF-INSURED r ,. SURETY BOND J{7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r B. STATE FUND 6 CFO LETTER r 99. OTHER: <br /> r 3 INSURANCE r 6. EXEMPTION r 9. STATE FUND B CD 422 <br /> Check one til ad'mi•roam whidl add - he <br /> used for legal notirirations and mailing. r 1. FACILITY r 2. PROPERT1"OWNER r 3. TANICOWNER 422 <br /> I a m notKRatlom and mailin s will be sen to tank owner Unless box 1 cr is checked. --__ <br /> Cenrication <br /> ,'j tartly that the in/ rmatigovided harem is bus and accurate to the best of my knowletlge. <br /> SIG T OF APPLI T `^ DATE 424 PHONE 42,5 <br /> NME 0 AP l A (Pd- 426TITLE OF APPLICANT 427 <br /> 5TATE UST FACILITY NUMBER(For"I u!�Pww 428 199a UPGRADE CERTIFICATE NUMBER(For Racal use oMy) 429 <br /> 5 <br /> UPCF(1199 revised) Formerly SWRCS Form A <br />