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!I U"IED PROGRAM CONSOLIDATED RM <br /> �I <br /> KS ; <br /> UNDERGROUND STORAGE TANKS t FACILITY <br /> per it e) <br /> Page - of <br /> TYPE OF ACTION I' 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r S.C-RANGE OF INFORMA,,CN(Sceary,,,V,- r %.PERMANENTLY CLOSED SIT <br /> (Ctiecx one item only) <br /> [-4.AMENDED PERMIT 'a<al use only) r 3.TANK REMOVED 4()0 <br /> r 3. .cmpoRARY SRE CLOSURE ay <br /> 1.FACILITY!SITE INFORMATION a <br /> 3USiNESS NAME(Same as FACILITY NAME or OaA-Doing ausiness As) 3 FACILITT!z ��y I I ( I <br /> , <br /> F 19,90 III <br /> NEAREST CROSS STRE 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/OISTRICT- <br /> r, 1. CORPORATION <br /> 3USINESS TYPE ��INOIVIDUAL r 5. COUNTY AGENCY' <br /> 1. AS STATION r 3.FARM r 5.COMMERCIAL r 3. STATE AGENCY- <br /> 2 DISTRIBUTOR r 4.PROCESSOR r S.OTHER r 3. PARTNERSHIP <br /> 7 FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS 's faciiy on trldtan Reservatan or "f owner of UST-s a owl'c agencr.name cr sucenrisor of <br /> REMAINING AT SITE 7usnanas? an moon,section or afte wncn otxrates the UST. <br /> (Tha is the contact arson for the tarot remres.) <br /> 404 r Yes r No 405 4W <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> - _ T 0� <br /> MAILING OR STREET ADDRESS 409 J ( r ! <br /> CITY 4t0 STATE att ZIP CODE /a7t2 �� <br /> PROPERTY OWNER TYPE r 2 INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 3. STATE AGENCY 413 � <br /> r 1. CORPORATION ;./PARTNERSHIP r 5. COUNTY AGENCY r 7. FEOERALAGEENCY <br /> III.TANK OWNER INFORMATION <br /> f <br /> TANK OWNER NAME 414 1 ?HONE 415 i <br /> MAILING OR STREET ADDRESS 416 i <br /> AZAIALZ--/, - <br /> TIT 417 STATE r 418 ZIP CODE 419 <br /> TANK OWNER TYPE (0.)NON10UAL r 4. LOCAL AGENCY i 01STRICT r 3. STATE AGENCY 420 <br /> F1 CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> I <br /> TY;TK)HO 4 4 I Call(916)322-9669 if questions arise 421 <br /> V 0E-T12nI FTIM IfCTPIMA Mr1A1 RFCP(]NSfRtf ITY <br /> INDICATE METHOO(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOVT MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r�STATE FUND 8 CFO LETTER r 99. OTHER <br /> rfNSURANCE r 3. E7(EMPTION r 9. iTATE FUND a CO '422� i <br /> ! <br /> C.tiecx one oox to indicate wnich address should oe used for legal notifications and marling_ [ 1. FACIUTY r 2. oROPERTY OWNER r 3. TANK OWNER 123 <br /> at notifications and marlin s will be sent to me tans owner unless oox t or 2 is check <br /> t <br /> I <br /> Candicatlon: f certify that the irlforf"uon crovideo herein is true and adairate to the OeSt of My knOwledge. <br /> SIGNATURE OF APPLICANT ]ATE 424 PHONE 425 <br /> NAME OF APPLICANT(print) 4261 -1TLE OF APPI--CkNT 427 <br /> STATE UST FACILITY NUMBER(Forlacal use only) 42B '998 UPGRADE CERTIFICATE NUMBER(Forrocar use only) 429 <br />