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' UWVFIED PROGRAM CONSOLIDATED FO <br /> II <br /> f[{j <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of <br /> TYPE OF ACTION j 1.NEW SITE PERMIT F 3.RENEWAL PERMIT SC5.CHANGE OF INFORMATION(Specify change- F 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> F 4.AMENDED PERMIT local use only) F 8.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY i SITE INFORMATION <br /> BUSINESS NAME(Sarre as FACILITY NAME or DBA-Doing Business As) 3 .FACILITY ID#. " '':I' <br /> r12EYYlIII St-! L� F Rr O b $ b13111 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE F 4. LOCAL AGENCY/DISTRICT- <br /> t4- <br /> GENCY/DISTRICT-t4- F71 LjbT F 1. CORPORATION F 5.COUNTY AGENCY- <br /> BUSINESS TYPE ICI GAS STATION F 3.FARM F 5.COMMERCIAL 2. INDIVIDUAL <br /> F 6.STATE AGENCY' <br /> F 2.DISTRIBUTOR F 4.PROCESSOR F 6+OTHER F 3. PARTNERSHIP F 7. FEDERALAGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is fad14 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 r �y Yes K No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 I C ® \ PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 4107 d G 1�� STATE 411 ZIP CODE� 412 <br /> i l `../l 2-0 5- <br /> PROPERTY OWNER TYPE . INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATEAGENCY 413 <br /> F 1. CORPORATION F 3. PARTNERSHIP F 5. COUNTYAGENCY F 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE F 2.INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT F 6.STATE AGENCY 420 <br /> F 1. CORPORATION j' 3.PARTNERSHIP F 5.COUNTYAGENCY F 7. FEDERALAGENCY <br /> TY(TK)HQ 4 1 4 Call(916)322-9669 if questions arise 421 <br /> Ft- <br /> INDICATE METHOD(S) r 1.SELF-INSURED r 4.SURETY BOND r"7. STATE FUND F10.LOCAL GOV=T MECHANISM` <br /> F 2.GUARANTEE F 5. LETTER OF CREDIT X 8. STATE FUND&CFO LETTER F 99.OTHER: <br /> F 3. INSURANCE r 6.EXEMPTION F 9. STATE FUND&CD 422 <br /> Check one box to'ndicate which address should be used for legal notifications and mailing. r 1.FACILITY 9 2. PROPERTY OWNER F 3.TANK OWNER 423 <br /> 1 ecial notifications a the tank owner unless box I or 9 is checked <br /> Certification:I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> TURE APPLI T� A&L DA 424 PHONE 425 <br /> NAME OF APPLICANT(print) m I C H pE L D®M ilk G U.4E 4 TITLE OF APPLICA OWNER <br /> 27 <br /> STATE UST FACILITY NUMBER(Forlocal use only) 4 1998 UPGRADE CERTIFICATE NUMBER(Fortoctal use only) 429 <br /> 1 IPOF f1/00 royicoril 5 Fnrmwrly C\A/RC Fn A <br />