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AL <br /> UNI IED PROGRAM CONSOLIDATED F0 <br /> TANKS <br /> UNDERGROUND ST - FACILITY <br /> (one page per site) <br /> Page _ of <br /> TYPE OF ACTION j 1.NEW SITE PERMIT F 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION(Specify change- I' T PERMANENTLY CLOSED SITE <br /> (Check one item only) I'4.AMENDED PERMIT local use only) r 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 to#. <br /> NEAREST CROSQS S EEr 5 401 n� A ILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> / ��� K e . CORPORATION <br /> 15. COUNTY AGENCY* <br /> BUSINESS TYPE 1.GAS STATIONe F 3.FARM F 5.COMMERCIAL F 2. INDIVIDUAL <br /> r 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR F 4.PROCESSOR h 6.OTHER I�3. PARTNERSHIP I' 7. FEDERAL AGENCY` 402 <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 �7 F Yes V(No 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 'n -:):-AC-- -734-- 61i`00 <br /> MAILING OR STREE ADDRESS 409 <br /> S® 2qo <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> r" <br /> "- i W 3Da <br /> PROPERTY OWNER TYPEF 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> 1. CORPORATION r 3. PARTNERSHIP I' 5. COUNTY AGENCY I' 7. FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PH�E s�t���-C� <br /> MAILING OR STREET ADDRESS - 416 <br /> CITY 417 /I STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE 12. INDIVIDUAL I 4. LOCAL AGENCY/DISTRICT I 6. STATE AGENCY 420 <br /> 1. CORPORATION I 3. PARTNERSHIP I 5. COUNTY AGENCY I 7. FEDERAL AGENCY <br /> TY(TK)=HQ4 4 - ® 3 a '7 Call(916)322-9669 if questions arise 421 <br /> TY JK) <br /> INDICATE METHOD(S) 1. SELF-INSURED I 4. SURETY'BOND P 7. STATE FUND r' 10. LOCAL GOV=T MECHANISM <br /> I 2. GUARANTEE I 5. LETTER OF CREDIT I B. STATE FUND&CFO LETTER I 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for log ns and mailing. r 1. FACILITY T 2. PROPERTY OWNER 3. TANK OWNER 423 <br /> L al notfi ti ns nd ma=d will be nt o the tank unless x 1 or ichecked. <br /> Certification: I certify that the info ti provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHO 425 <br /> I OIL) <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> I qa <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />