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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> loe (one page per site) Page_of <br /> TYPE OF ACTION I.NEW SITE PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINEIL <br /> S NAME(Same s FACILITY AME or DBA-Dcing Busines As) 3 FACILITY ID# <br /> l <br /> 'ok <br /> NEAREST CR SS STREET 401 FACLITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' <br /> 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS n I.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indi n Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands 7 operates the UST(This is the contact person for the tank records.) <br /> 404 ❑ Yes VN. 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> OPER Y OWNER NAt,, I 407 PHONE 408 <br /> VIC <br /> MAILING OR STREET ADDRESS C� 409 <br /> Y 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE VI.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> NK O ER NA E ` 414 PHONE 415 <br /> i�L , e_7 <br /> M ILI G OR STREET ADDRESS r 416 <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE Lrl.CORPORATION 2.INDIVIDUAL 04.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 420 <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK)HQ 44- Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND STATE FUND [:110,LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT In 8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING AD'jMkESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY 2. PROPERTY OWNER ❑3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certificat' - certify thatjhe info vided herein is tru nd accurate to the best of my knowledge. <br /> RME <br /> TUR APP T DATE 424 PHONE 425 <br /> fmm <br /> 1 OF PLICA pri a 426 TLE OF APPLICANT 427 <br /> S TE UST FA NUMBER(For local use only) 428 1998 UkqYADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />