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UP" IED PROGRAM CONSOLIDATED : ' R,M, <br /> F. <br /> TANKS <br /> 1 UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION j 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> r a.AMENDED PERMIT IOCa/use only) r 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> �bAl.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FAC PTY N ME or D A-0' Business As) FACILITY 10 i <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE <br /> F" t. CORPORATION r 4. LOCAL AGENCY/DISTRICT' <br /> r 5. COUNTY AGENCY- <br /> BUSINESS TYPE GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r OTHER r 3. PARTNERSHIP r 6. STATE AGENCY' <br /> 403 r 7, FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of I <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. ! <br /> (This is the contact person for the tank records.) <br /> 404 1-5 r Yes ANo 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 40 <br /> a <br /> MAILING OR STREET ADDRESS 409 <br /> I <br /> c a <br /> C17Y 10 STATE 411 ZIP CODE 412 <br /> PROPERTY OWINEER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION [' 3. PARTNERSHIP r S. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> I <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 4161 <br /> I <br /> i <br /> I <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> I <br /> f <br /> TANK OWNER TYPE INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY i <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM j <br /> F 2. GUARANTEE X5. LETTER OF CREDIT r 8. STATE FUND&CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> [i;iir';box to indicatewhich address should be used for legal notifications and mailing. I' 1. FACILITY r 2. PROPERTYOWNER r 3. TANK OWNER 423 <br /> ations and matlinbs will be sent to the tank owner unless box 1 or 2 is checked. _ 1 <br /> t <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 FACILITY NUMBER(For local use only) 47 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />