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�ZIZ I0Z <br />. r 1` ` <br />UNIFIED PFiOGRA-M CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(One page per site) Page L of <br />TYPE OF ACTION 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE 400. <br />(Check one item only) ❑ 4. AMENDED PERMIT (Specify change) ❑ 8. TANK REMOVED <br />❑ 6. TEMPORARY SITE CLOSURE <br />L VACILITYIITE moi) CATION <br />BUSSS NAME (Same as FACILITY NAME. or DBA - Doing Business As) 3. <br />FACILITY <br />ID# r.4 <br />`r�\O <br />�,� 9L. <br />3 <br />N AREST CROSS STREET 4o1. <br />FACILITY OWNER TYPE 4. LOCAL AGENCY/DISTRICT* 402. <br />rr j �•" . �- <br />❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />BUSINESS ❑ 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL 403. <br />❑ 2. INDIVIDUAL 6. STATE AGENCY* <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR V 6. OTHER <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS 404. <br />Is facility on Indian Reservation 405. <br />* If owner of UST is a public agency: name of supervisor of division, section or 406. <br />office which operates the UST. (This is the contact person for the tank records.) <br />REMAINING AT SITE <br />1 <br />or trust lands? <br />❑ Yes No <br />iI. PROPPRTY OBER <br />INFORMATION <br />P OP TY OWNER NAME aoz PHONE - aos. <br />MAILING OR STREET A15DRESS 409. <br />zTs3 <br />CIT 410. <br />STATE 4H. <br />ZIP CODE 412. <br />(l�C M <br />PROPERTY OWNER TYPE 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY / DISTRICT 6. STATE AGENCY a13. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />III. TANK OWNER INFOO RMATION <br />TANKrOWNER NAME ( ( ala. PHO ZO V'j <br />MAILING OR STRPET ADD SS alb. <br />CITY 417. <br />STA 418. <br />1 ZIP CODE p 419. <br />TANK OWNER TYPE 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY/DISTRICT 6. STATE AGENCY 420. <br />3. PARTNERSHIP 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD til :EQUA 1 TION MT STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- 1 1 Call 916 322-9669 if questions arise 421. <br />V�PE'R►LEUM"T' ANCIALRESPONSIKIITY <br />INDICATE METHOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND 10. LOCAL GOVT MECHANISM 422 <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER 99. OTHER. <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD <br />�v YL LEGAL.�+il?TIRIC�i'I`�C1N•Ai�'1) h�IAiLING �DI3IiSS <br />Check one box to indicate which address should be used for legal notifications and mailing. <br />Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked L FACILITY E12. PROPERTY OWNER ❑ 3. TANK OWNER 423. <br />VII. APPLICAN I PIA I iJ ' <br />Certification: I certify that the informat#n provided herein is true and accurate to the best of my knowledge. <br />SIG OF T <br />DATE 424. <br />PHO 425, <br />p �/J <br />F PLICANT nt) _ a26. <br />TITLE OF APPLICANT az <br />_ <br />STATE UST FACILr NUMBER (A; gency use only) 428• <br />1998 UPGRADE CERTIFICATE NUMBER (Agency use only) 429. <br />(See Data Element 1 above. <br />UPCF Hwfwrc-a (1/99) -1/2 http://www.unidocs.org Rev. 02/16/00 <br />