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UNIFIED PROGRAM CONSOLIDATED FORM Dr <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION �1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> [16,TEMPORARY SITE CLOSURE <br /> CILITY/SITE INFORMATION <br /> BUSINESS NAME(same as FjCILITYNAMEor DBA-Doing Badu--Aa) s. FACILITY <br /> r0. ' 1 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- <br /> lY1G C1.CORPORATION El 5.COUNTY AGENCY" <br /> BUSINESS .GAS STATION U,,ARM LJ5.COMMERCIA.L 4a3. K2.INDIVIDUAL [16.STATE AGENCY• <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER [13.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation nes. *if owncr of UST is a public agency:tame of supervisor of division, section or 406 <br /> REMAINING AT SITE or trust lands? once which operates the UST. (This is the content person for the tank records.) <br /> ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME ^ , 401 PHONE 408, <br /> tio8 r X99 u cob <br /> MAILING OR STREET ADDRESS a09. <br /> L13 1mu.4:� s+. <br /> CITY ala. 1 STATE Ciq 411. 1 ZIP CODE SO a_ atx. <br /> Lon CL� <br /> PROPERTY OWNER TYPE L CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 4O <br /> [13.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONECiO 399 . 149 r els <br /> MAILING OR STREET ADDRESS lfl 416. <br /> L!aC. � . <br /> CITY 417. 1 STATE 41 s. ZIP CODE -� 419. <br /> TANK OWNER TYPE ❑1.CORPORATION [:12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY azo. <br /> [-13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 42L <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED [14.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM 412 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER; <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check oro bon to indicate which address should be used for legal notifmatiom and mailing. <br /> Legal notifications and trailings will be sent to the teak owncr unless box 1 or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that the inforrration provided herein is true and actuate to the best of my knowledge. <br /> SIGN F DATE 42a. P ONE 425. <br /> 8 a /va `civ$ �ya•81080, <br /> T�rXME OF APPLICANT(print) 426. TITLE OF APPLICANT 437, <br /> rA la �C /c <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429_ <br /> (See Data Element 1,above. <br /> UPCF Hw wrc-a(1/99).1/2 http://www.unidocs.org Rev.02/16/00 <br />