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UNIFIED PROGRAM CONSOLIDATED FIRM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of <br /> TYPE OF ACTION j' 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Sped7y change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> r 4.MENDED PERMIT lac2/use only) r B.TANK REMOVED 400 <br /> r 6 TEMPORARY SITE CLOSURE <br /> r 1.FACILITY I SITE INFORMATION <br /> BUSINESS NAME( e as FACILITY NAME or DBA-Doing Business,As) /IYi 31 FACILITY ID <br /> L(� <br /> NEWS R SSTREET 40 FACILITY OWNER TYPE ]'4. LOCAL AGENCY/DISTRICT' <br /> L- F 1. CORPORATION F S. COUNTYAGENCY` <br /> BUSINESS TYPE r 1,GAS STATION r 3.FARMyyr 55 COMMERCIAL r 2. INDIVIDUAL 6STATEAGENCY- <br /> 2. <br /> TATEAGENCY'2.DISTRIBUTOR r 4.PROCESSOR �OTHER r 3 PARTNERSHIP r .r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS la fedliry on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE T_ lrustkn0a? division,section or office which operates Me UST. <br /> //`l/f (This is the contact person for the tank recomls.) <br /> 404 ryes A. <br /> 405 406 <br /> It.PROPERTY OWNERINFORMATION <br /> PROPERTY ONMER NAME 407 ONE 408 <br /> 1 r �0 31- o <br /> MAILIN Oft REET ESS 409 <br /> CI .1U 51AII, 411 ZIP CODE 412. <br /> C4S�' O� <br /> PROPERTY OWNER TYP r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 413 <br /> �1 CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7 FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK.;EYE ER E 414 PHONE 415 <br /> T" 1W ao '731-6 <br /> MAILIfR STREET A SS 415W r <br /> I � t <br /> CITY D STATEB 1 E 419 <br /> vC� <br /> TANK OWNERTYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 420 <br /> CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HQ 4 4 - 01�6"Oil <br /> Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND �r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r S. LETTER OF CREDIT psA. STATE FUND a CFO LETTER r 99. OTHER: <br /> F 3 INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Check one box to iMicate which address shwltl ba used for legal notiBmtions aM maiing. r 1. FACILITY r 2. PROPERTYOWNER r 3. TANKOWNER 423 <br /> Legal i ns nd mailin s will be nl to to t nk own runless box 1 or 2,5 <br /> Certification. I certify that the iMormation provided hansom is Wa and accurate to the beat of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(pdrrt) 428 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local um only) 428 1998 UPGRADE CERTIFICATE NUMBER(For iocef use only) 429 <br /> AA 3)loc <br /> UPCF(1/99 revised) 6 1 �'�Q� V O Formerly SWRCB Form A <br />