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UNIFIED PROGRAM CONSOLIDATED FORM d <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION �1.NEW PERMIT [13.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> 400. <br /> (Check one item only) ❑L AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(S.as FACILITY NAMEor DBA-Doiry Business b) 3. FDA#ILITY <br /> rA f O 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• 402 <br /> NEAREST CROSS ST T ^� <br /> El1.CORPORATION ❑5.COUNTY AGENCY' <br /> /11CC rc✓ I C000.GOO <br /> BUSINESS LJQ.GAS STATION U 3.FARM 5.COMMERCIAL <br /> 403 X2.INDIVIDUAL ❑6.STATE AGENCY• <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' 4a <br /> TOTAL NUMBER OF TANKS Is facilityon Indian Reservation 403. •If owner of UST is a public agency-name of supervisor of division,section or <br /> REMAINING AT SITE or flus[la�ndfs? office which operates the UST. (This is the contact person for the tank records.) <br /> Z ❑Yes Ial No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME . 407 PHONE <br /> 408. <br /> asA�W3 L_LL w <br /> (40W . <br /> MABINOR STREET ADDRESS <br /> CITY v ,MU409. <br /> 410 STATE ail ZIP CODE 13 412. <br /> Qn(J-' 413. <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVB)UAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> [-]3.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> ETANKOWNER NAME 414. PHONE 415. <br /> a uo 399 . y e a416STREET ADDRESS <br /> 419. <br /> 4n. STATE ua. ZIP CODE <br /> TANK OWNER TYPE ❑ I.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUMY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44- <br /> Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHODS) ❑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 /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicatewhich address should 6us <br /> c ed for legal notiRcatiOns and nessiling. 2. PROPERTY OWNER 3.TANK OWNER 421. <br /> ugal notifications arld mailings will be sent to the tank owmr unless box 1 or 2 is checked [1 1.FACILITY ❑ ❑ <br /> VII.APPLICANT SIGNATURE <br /> CertificatiDATE on: 1 certify that the information provided herein is nue and accurate to the best of my knowledge. 434 P D <br /> E OF APPLICANT(print) NE 423. <br /> SIGN RE F S a /va �ro� 9va •St�S�• <br /> 426. TITLE OF APPLICANT 4zn <br /> /� <br /> /1 7.J { <br /> STATE UST FACILITY NUMBER(Aee�cy ix only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Asency�x omy) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 <br /> httpJ/"w.unidocs-org Rev.02/16/00 <br />