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10/30/2003 11:41 2094683(', FIFTH FLOOR PAGE 17
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<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> TANKS
<br /> UNDERGROUND STORAGE TANKS -FACILITY
<br /> (One page Per sitc) Page of-5- `
<br /> TYPE OF ACITQN g1 I.NPW PERMiT ❑3.RENEWAL PERMIT ❑5.CHANGE OFtNPORMATION ❑ QNTLY CLOSED ME.7.PERMAN4M-
<br /> (Cheek 1111!ltim only) 'T [14.AMENDED PERMTr(Specify cbeoge)
<br /> ❑6.TEMPORARY SITE CLOSURE ❑8,TANK REMOVED
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<br /> NEARE3TSS TRLeET, 401, FACILI'T'Y OWNER TYPE 4.LOCAL AGENCYIDISMCT* 40Z
<br /> oZlo% X1•CORPORATION ❑5.COUNTY AGENCY*
<br /> 13USO ESS Erl.GAS STATION Ll 3,FARM U 5.COMMERCIAL 40' ❑2.INDIVIDUAL ❑6.STATE AGENCY-
<br /> TYPE [1.2.DISTRIBUTOR ©4,PROCESSOR ❑6.OTHER ❑3.PARTNERS111P ❑7,FEDERAL AGENCY"
<br /> TOTAL NUMBER OF TANKS IS facility o0 Indiao Reservation 4W. 'If owner of UST ie i Pt,blic agency;name of euperviror of dMsioo,sw ion or 406.
<br /> REMAINING AT SITe /f or trust lands? office which opnuns the UST. (This is the comm perm for the tank records.)
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<br /> MAIUNCy OR ST011V ADDRESS 4
<br /> CITY 410. STATE 411. ZIP CODE / l�d ♦12
<br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4_LOCAL AGENCY/DISTRTCT b STATE AGENCY 413.
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<br /> T IY �ERNAME 414. PT10NE 41s.
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<br /> MA INGi R 9TIWT ADDRIESS r 416,
<br /> CITY 417. STATE 418. 1 ZIP CODE /„�'J / 419,
<br /> TAMC OWNER TYPE L CORPORATION ❑2ANDIV IDUAL ❑4,LOCAL AGENCY/DrSTRICT ❑ll 6..STATE AGENCY 4=1
<br /> 3,PARTNERSHIP ❑S.COUNTY AGENCY 7,FEDERAL AGENCY
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<br /> TY K 1I 44- Call 916 322-9669 if questions arise 421-
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<br /> INDICATE METHOD(S) ❑1.SELF-INSURED ❑4,SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422.
<br /> �3GUARANTEE [J 5.L[ITPER OF CREDIT (3 a.STATE FUND&cFo LETTER Ll99.OTHER:
<br /> .INSURANCE ❑6,EIEMTTION ❑9.STATE FUND&CD
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<br /> Check ow box rot iadirare whiob address should be used for kgal meficatiom and mailing.
<br /> Legal nodi cations and mailings will be sm to the took owner tmkss box I oc 2 is check.& ❑ I.FACII.ITY /[ • PROPERTY OWNER [33.TANK OWNER 421.
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<br /> Cendiicstion: I Certify 11 at the Wfbr=ian vidad Ivercinjil true and aeemte to the hast ofmy logwkdgr.
<br /> SIGNATURE OF DATE 424_ PHONE 44,
<br /> 71�NT 426' TITLE OP [CA 42I.
<br /> hav) rD�Lv7 Ar�1
<br /> STATE UST FACILITY NUM13ER(Agency use onb) 4211. 1998 UP R CERTIFICATE NUMB (Ag..y are only) 429-
<br /> (See Data Element 1,above,
<br /> UPCF Bw hn-0-a(1/99)-1/2 MIp://www.unidocs.org Rev.OV16MO
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