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UNIFIED PROGRAM CONSOLIDATED A7FORM <br />UNDERGROUND STORAGE TANKS - FACILITY TANKS <br />%ane page per site) <br />TYPE OF ACTION r I. ,NEW SITE PERMITPage _ Sf _ <br />fch1 etnertem Doty) r3. RENEWAL PERMIT ri. CHANOEOFINFORMAT;ON iSoovry oMnge- ri. r PERMAN <br />ENRY CLOSED SITE a AMENDED PERMIT op m omyl 3. TANK REMOVED a <br />1 I CORPORATION - • Lw1..LL nocncrrulSi RIOT 1 5. STATEAGENCY 420 <br />F 3. PARTNERSHIP r S. COUNTYAGENCY r 7 FEDERALAGENCY <br />I TY ;TK) HQ 14 1 4 I I I I I I( I Calf (916) 322-9669 if questions arise N S A 21 <br />:NOICATE METHOD(S)) [' 1. SELF-INSURED r 4 SURETY BOND r 7. STATE FUND <br />r 10. LOCAL GOV=T MECHANISM <br />r Z GUARANTEE r i. LETTER OF CREDIT r 9. STATE FUND 8 CFD LETTER r 99. OTHER <br />r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND d co 422 1 <br />cr <br />Clete ba t a nh oo slltuM be eo f egal Ifiq s arq mallrq. <br />r <br />I. FACILITY I SITE INFORMATION <br />- _wIal nanhtaupm and matlin s willbe senrt me loot cwn v amass Day 1 or � is rnedle¢ 1, FACILITY <br />3USINESS NAME (Same as FACILITY NAME w DBA- Oamg dluness As) 7 FACILITY!0 a <br />CAPITOL AUTO SALES <br />1 <br />1 NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE <br />1 <br />I' I. CORPORATION <br />r a. LOCAL AGENCY pISTRICT• <br />3USINESS TYPE [ I. GAS STATION <br />r 7. FARM r�i. COMMERCIAL r 2 :NONIOUAL <br />r 5, COUNTYAGENCY <br />r 2. DISTRIBUTOR <br />, <br />r 4. PROCESSOR r 6. OTHER 3. PARTNERSHIP <br />r S. STATE AGENCY• <br />403 <br />r 7. FEDERALAGENCY• <br />OTAL NUMBER OF TANKS <br />REMAINING AT SITE <br />Is faaery on IIIeWn Reserva,gn w •Y Sumer of UST s a puow agarlty: name cf svoemsw at <br />402 <br />ONE 404 (KNOWN)rvee <br />mwams7 arvmon. semonwarnn wnrh avmatea ;ne UST. <br />h mem Iaa oe sm o me an ecn>I <br />I <br />11. PROPERTY OWNER INFORMATION <br />PROPERTY ONMER NAME 401 <br />JAGENDER SINGH <br />PHONE 408 <br />MAILING OR STREET ADDRESS 4 09 <br />7 <br />650 E. MINER AVENUE <br />CI <br />TOC <br />STATE a11 <br />IPCO E 412 <br />CA <br />95202 1 <br />I <br />PROPERTY OWNER TYPE X r 2 NOIVIOUAL � <br />r 1. CORPORATION r 4 LOCALAGFNCYloISTi C' <br />r <br />I 3. PARTNERSHIP r <br />5. STATEAGENCY 413 <br />S COUNTYAGE.NCY <br />r T FEDERALAGE4CY <br />I <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />SAME AS PROPERTY <br />OWNER INFORMATION ABOVE <br />HONE s <br />la <br />!AILING OR STREET ADDRESS 416 <br />Clr' 417 <br />STAiE 418 <br />I LIPCODE 419 <br />ANK OWNER TYPE1- <br />1 I CORPORATION - • Lw1..LL nocncrrulSi RIOT 1 5. STATEAGENCY 420 <br />F 3. PARTNERSHIP r S. COUNTYAGENCY r 7 FEDERALAGENCY <br />I TY ;TK) HQ 14 1 4 I I I I I I( I Calf (916) 322-9669 if questions arise N S A 21 <br />:NOICATE METHOD(S)) [' 1. SELF-INSURED r 4 SURETY BOND r 7. STATE FUND <br />r 10. LOCAL GOV=T MECHANISM <br />r Z GUARANTEE r i. LETTER OF CREDIT r 9. STATE FUND 8 CFD LETTER r 99. OTHER <br />r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND d co 422 1 <br />cr <br />Clete ba t a nh oo slltuM be eo f egal Ifiq s arq mallrq. <br />r <br />- _wIal nanhtaupm and matlin s willbe senrt me loot cwn v amass Day 1 or � is rnedle¢ 1, FACILITY <br />r i PROPERTY OWNER r 3. TANK OWNER +27 <br />1 <br />CartAlcaUon: tetlRy Ina1 In infolmalan OfOeaep netts is w9 atq xCyfale Io Itb hesl0f mY YnoMaoge. <br />SIGN RE OFAP I T <br />DATE <br />'4411-u _ o, <br />I <br />NAM F APPLICANT (pnm) Y <br />32s PHONE 425 <br />Iz� szy Z �s 0 <br />428 I O APPLICANT <br />MR. JAGENDER SINGH ( nLtelrn <br />427 <br />9 0 <br />