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- - 0 IN I <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY i <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION F 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4.AMENDED PERMIT local use only) F 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY 10 <br /> I <br /> p -l14 " <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> ,,,,C----�../11. CORPORATION I' 5. COUNTY AGENCY- <br /> BUSINESS TYPE r 1. AS STATION r 3.FARM r 5.COMMERCIAL 1(2• NDIVIDUAL r 6. STATE AGENCY' <br /> 2.DISTRIBUTOR r 4.PROCESSOR F 6.OTHER 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a ouolic agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404r Yes r No 405 406 <br /> ,q iv/C <br /> II.PROPERTY OWNER INFORMATION <br /> PHONE 408 <br /> PROPERTY OWNER NAME 407 <br /> MAILING OR STREET ADDRESS 409 <br /> STATE all ZIP COD 412 <br /> clrr a10 <br /> PROPERTY OWNER TYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> r 1. CORPORATION F 3. PARTNERSHIP F 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> TANK OWNER NAME 4 <br /> M <br /> MAILING OR STREE AD KESS 416 �/ I <br /> V l �H Y STATE 418 ZIP CODE 419 <br /> CITY 417 <br /> Com- 1 5 33 G <br /> TANK OWNER TYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> F 1. CORPORATION F 3. PARTNERSHIP F 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> TY(TK)HO 4 4 - 1�7 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) F 1. SELF-INSURED F 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE F 5. LETTER OF CREDIT r 8. STATE FUND&CFO LETTER r 99. OTHER: 422 <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CO <br /> AKir <br /> Check one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Lenal notifications and marlin s wilt be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: I certify that the info. ' n Proved herein iQbe and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT c _.. DATE �� c7 424 PHON e �� q O 5 <br /> NAME OF APPLICANT(pont) , 426 TITLE OF APPLICANT ` 427 ,�/ Y j/ <br /> STATE UST FACILITY NUMBER(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fcrlocal use only) 429 <br />