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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only) 04.AMENDED PERMIT(Specify change)_Signature/date ❑S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAM E(Sameas FACILITY NAME or DBA-Doing easlnco M) 3. FACILITY <br /> Estes West dba GI TRUCKING COMPANY IDN <br /> NEAREST CROSS STREET NII. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- 102- <br /> Stitnson Road ® 1.CORPORATION [15.COUNTY AGENCY* <br /> BUSINESS I.GAS STATION 3.FARM M 5.COMMERCIAL 403. [12.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR [14.PROCESSOR ®6.OTHER [13.PARTNERSHIP [17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404 Is facility on Indian Reservation 403_ *If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST (This is the contact Person for the tank records.) <br /> ONE ❑Yes ONO <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 40a. <br /> Estes Terminals of Califomia,LLC 804-353-1900 <br /> MAILING OR STREET ADDRESS apy <br /> PO Box 25612 <br /> CITY 410, 1 STATE 411. ZIPCODE 4u. <br /> Richmond VA 23260 <br /> PROPERTY OWNER TYPE ® I.CORPORATION E12.1 ]DUAL 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION- <br /> TANK OWNER NAME 414. PHONE 415. <br /> Estes Terminals of California LLC 804-353-1900 <br /> MAILING OR STREET ADDRESS 476. <br /> PO Box 25612 <br /> CITY 417 1 STATE 41x. ZIPCODE 419, <br /> Richmond VA 23260 <br /> TANK OWNER TYPE 19 L CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <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 0 0 1 7 1 4 1 ( 1 0 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED [14.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM <br /> [32.GUARANTEE r]5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER El 99.OTHER: 42x. <br /> [13.INSURANCE [16.EXEMPTION [19.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ® 1.FACILITY ❑2. PROPERTY OWNER [13.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information pr here' is true ccurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 4x4- PHONE 425, <br /> 6/02/11 <br /> rNAEPPLI T(print) 426_ TITLE OF APPLICANT 427 <br /> Aed <br /> FACILITY NUMBER(Agent.use om1 4� 1998 UPGRADE CERTIFICATE NUMBER(Ag a ON,) 429ment I,above. <br /> I PCF HwN rc-a(1/99)-1/2 http:/4 .unidws.org Rev-02/16100 <br />