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r <br /> HfH <br /> UNIFIED PROGRAM CONSOLIDATED FORM d <br /> n'A TANKS <br /> COO UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> EW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Chock..item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> TrCILITY/SITE INFORMATION <br /> BUSINESSNAME(sameu FACILITY NAME or DBA-Doing Business Ad 3, FACILIITY <br /> YQ IDp N i l <br /> NEAREST CROSS s'rntr 7 3101 hr 4a3. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' 402. <br /> 171d.C. f <br /> G -r- I f000.(AKX O ❑ I.CORPORATION El5.COUNTY AGENCY" <br /> BUSINESS . AS STATION U 3.FARM CTS.COMMERCIAL 403. X2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 404 Is facility on Indian Reservation 405. 'If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE Z or trust lands? office which operates the USC (This is Ile<maacl person Por the rank rccodc) <br /> ❑Yea [%No <br /> II. PROPERTY OWNER INFORMATION - <br /> PROPERTY OWNER NAMEON ^ 407 PHONr �`99 • A 406 <br /> MAILING OR STREET ADDRESS /-la�Ai-_Y_L1q_' . �1E 4m <br /> L/3 � , ma.t:,3 5+. <br /> CITY 4107STATE 411- ZIPCODE 4D. <br /> aAs CIS 9so3 <br /> PROPERTY OWNER TYPE I.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME4147 PHONE 415, <br /> ae 40 6 yq �a <br /> MAILING OR STREET ADDRESS 4167 <br /> 4 a C. 1 <br /> CITY 4n, STATE ua. ZIP CODE 9 419 <br /> TANK OWNER TYPE ❑ 1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCYIDISTRICT ❑6.STATE AGENCY 4N. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY 0 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 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑L SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422. <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE - ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check area box Io indicate which address should be used for legal notification and mailing. <br /> Legal notification and mailings will be sent to the lank owner unless box I or 2 is checked ❑ 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I cenify that the information provided heroin is clue and accurate to the best of my knowledge. <br /> SIG RE F DATE 424. 1 P1iONE 425. <br /> 8 a /Oa `Nva 9 va 8108(0- <br /> E OF APPLICANT(print) I� ' 426. TITLE OF APPLICANT m. <br /> TK/{ <br /> STATE UST FACILITY NUMBER(Agency use only) 429, 1998 UPGRADE CERTIFICATE NUMBER(Agency one only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 litip://www.utii,ioes.org Rev.02/16100 <br />