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UNIFIED PROGRAM CONSOLIDATED FORMQ di�o�Y' TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY lI� <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 16 3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(S.me..FA/CIUry AME or DRA-M.rte R.sin.As) 3 FACILFrYID# 1 <br /> p 401 FACI Y OWNER TYPE ❑4.LOCAL AGHNCIC <br /> Y/DISTRT <br /> NEAREST CROSS STREET ' <br /> _ /•„��.-. ❑ 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUS S I.GAS STATION 3.FARM vr+ LJ 5. COMMERC L PQ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TO-LM <br /> 4L NUBEOF <br /> R TANKS Is facility on Indian Reservation or 'If owner ofUST is a public agency:came of supervisor ofdivisiorL scetion or office which <br /> REMAINING,AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> ao4 ❑ Yes No 405 °06 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER N��.++E 402 PHONE 408 <br /> y� e �✓2oxz1 24�i -YAG - S >� <br /> 409 <br /> MAIyING OR STREET ADD SS <br /> rLJVAI 38 <br /> CITY °10 STA1�, all ZIP CODE a¢ <br /> PROPERTY OWNER TYPE I.CORPORATION 2g.2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> -,I j3.PARTNERSHIP ❑5.COUNTY AGENCY ❑1.FEDERAL AGENCY as <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME a4 PHONE 415 <br /> ��� T u�� �/GG 0833 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> '-0 33 <br /> CRY 41v STATE 418 ZIP CODE 419 <br /> elet <br /> TANK O TYPE, 1.CORPORATION 2.INDIV(DUAL Lj 4.LOCAL AGENCY/DISTRICT LJ 6.STATE AGENCY 420 <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- �= T_ ��ii Call 916 322-9669 if uestions arise 421 <br /> a `V.PETF."OLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s)$I.SELF-INSURED ❑4.SURETY BOND J4 7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check oce bax to iMicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. I.FACILITY [12. PROPERTY OWNER ❑3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Cenificatio certify that the information provided herein is true wo accurate m the best of my knowledge. <br /> SIGN OF LIC T DATE az5 <br /> 42° PHONE <br /> NAM F APPLICA (p' t) <br /> 026 TITLE OF APPLICANT <br /> J43r <br /> � o � acus✓ <br /> STATE UST FACILITY NUMBER(For oc.l ase o.ly) 428 1998 UPGRADE CERTIFICATE NUMBER(Fntoala..my) 639 <br /> UPCF(1/99 revised) Forfnerly SWRCB Form A <br />