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UNIFIEDPROGRAMCONSOLIDATED FORM <br /> t 0 0 TANKS <br /> UNDERGROUND STORAGE TANKS -FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION(Specify change- I'7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> 1'4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IO# 1; <br /> ,. <br /> NEAREST CROSS STREE 401 FA TY OWNER TYPE <br /> r 4. LOCAL AGENCY/DISTRICT' <br /> CORPORATION <br /> r T'2. INDIVIDUAL r 5. COUNTY AGENCY' <br /> BUSINESS TYPE GAS STATION r 3.FARM r 5.COMMERCIAL 1-6. STATE AGENCY' <br /> I'3. PARTNERSHIP I'7. FEDERAL AGENCY' 402 <br /> T'2.DISTRIBUTOR T'4.PROCESSOR I 6.OTHER <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public 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 /> 404 I Yes No 405 406 <br /> II PROPE <br /> FiTY OWN!!R INFORMATION <br /> PROPERTY OWNER NAME 407 -PHO E 408 <br /> o c� - y v25 <br /> MAILIN ORSTREETADDRESS 409 <br /> c <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> �uC <br /> PROPERTY OWNER TYPE ]'2, INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> �1. CORPORATION T'3. PARTNERSHIP T'5. COUNTYAGENCY T'7. FEDERALAGENCY <br /> Sh 11 :1 334iA d'A� bi h' Yz'i <br /> r wII TANFC I�VIE�2INFO�2(V)ATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> ,, _ N <br /> MAILING R STREET ADDRESS 16 <br /> L <br /> CITY - 417 - STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPEIr 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT I'6. STATE AGENCY 420 <br /> *11-1, <br /> CORPORATION r 3. PARTNERSHIP r S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> I ail <br /> i' <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise azi <br /> INOICATE'METHOD(S} <br /> I' 1.SELF-INSURED I`4. SURETY BOND I'7.-STATE FUND � � r 10. LOCAL GOV=T I(dECHANISM <br /> r 2. GUARANTEE T'5. LETTER OF CREDIT r 8. STATE FUND 8 CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> 00 A;N <br /> �.,.. <br /> Cheek do i b"ox to indfca(e whlefi address should`6e used forl3gal notiFiCdt ons and mailing:" <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. I''L FACILITY 2. PROPERTY OWNER 1 3. TANK OWNER 423 <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OFAPPLICANT DATE 424 PHONE 425 <br /> NAM OF APPLICANT(print) 426 TI E OF APPLI ANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />