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I , <br /> U 7.0 PROGRAM CONSOLIDATED <br /> 0, <br /> I I <br /> TANKS ; <br /> I UNDERGROUND STORAGE TANKS - FACILITY <br /> I <br /> i (one page per sire) 'I <br /> Page _ of <br /> TYPE OF ACTION I' !.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5"CHANGE OF INFORMATION(Specify cnar,ge- r 7 PERMANENTLY CLOSED SITE <br /> !Checx one Tfem only) F 4 AMENDED PERMIT %ocal use only) r 3.TANK REMOVED 100 <br /> I_ 5.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> 3USINESS NAME(Same as FACILITY NAME or 08A-Jong Btasnness As) 3 FACILITY ID A <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE I 4. LOCAL.IGENCYf0ISTRICT- <br /> 1-(I g-- 0��n( l 1_ CORPORATION r i. COUNTY AGENCY' <br /> BUSINESS TYPE ;,GAS STATION r 3.FARM T 5.COMMERCIAL r Z. INDIVIDUAL <br /> 5. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4 PROCESSOR r 5.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> I OTAL NUMBER OF TANKS is facility on Inatan Reservation or '!f owner of UST is a puolic agency name of suoervnsor or <br /> REMAINING AT SITEuustlanas? och rvTsion.section or office which ooerates the UST. <br /> 3 (This�s the contact person for the cane records.) <br /> 404 res No 105 96 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 307PHONE 408 <br /> ?rp t� 6�0 -:54 b <br /> MAILING OR STREET ADDRESS 409 <br /> -p O X 6O <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYZ. IND(VIOUAL I_ 4. LOCAL AGENCY I DISTRICT I- i. STATE AGENCY 413 <br /> 1 CORPORATION F 3. PARTNERSHIP I� 5. COUNTY AGENCY I' 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 &HONE 415 <br /> �p +�12ot�T.S i <br /> MAIL,NG OR STREET ADDRESS 416 <br /> i�0 Rvo�C 6d�g <br /> 417 STATE 418 ZIP CODE 419 <br /> A CA <br /> TANK OWNER TYPE f r i INDIVIDUAL r 4. LOCAL.AGENCY I DISTRICT r i. STATE AGENCY 320 <br /> CORPORATION I" 3. PARTNERSHIP I- 5. COUNTY AGENCY I- 7 FEDERAL AGENCY <br /> CC r <br /> TY!TK) HQ 4 4 - �� O o 6I Cail(916)322-9669 if questions anse 421 <br /> NOICATE METHODS) 1 SELF-INSURED T 4. SURETY SONO I 7. STATE FUND I 10. LOCAL GOV=T MECHANISM <br /> h 2. GUARANTEE I' 5. LETTER OF CREDIT I 3. STATE FUND&CFO LETTER I- 99. OTHER' <br /> L 3. INSURANCE r 5. EXEMPTIONI 9. STATE FUNO&CO <br /> Cheec one oox to indlca[e wnlnn address should be used for"I notifications and mating. r ! FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> legal notifications and m. s wdl be sent to the tank owner wless box 1 or'-s merited. <br /> %111 A 221 ICA MIT SIGNATI IRE <br /> F. i ahi I cenify that the information provided herein is true and accurate to the best of my Knowledge. <br /> SIGNATURE OF APPLICANT I DATE 424 PHONE 425 j <br /> NAME OF APPLICANT(print) 426) TITLE OF APPLICANT 427 <br /> I <br /> I <br /> STATE UST FACILITY NUMBER(For local use only) s28) '998 UPGRADE CERTIFICATE NUMBER IFor,ocal use only) 429 <br /> v <br /> CD <br /> 3 <br />