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Sasso <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One Page per site) Page I of le <br /> TYPE OF ACTION ❑I.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7p.PERMANENTLY CLOSED S <br /> (Check one item 5only) ❑4.AMENDED PERMIT (Specify change) T-.TANK REMOVED Q <br /> [16.TEMPORARY SITE CLOSURE l <br /> ti <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Some as,FACILITY NAME or DBA-ming Basses As) 3. FACILITY '•,' _ <br /> R4.t f #&* 2 ai r ID# k I. <br /> NEAREST CROSS STREET -5'1 <br /> TREET .S 1( YJ-a!l Cc.9ot.. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT' 402. <br /> Frca IO n �❑'21.CORPORATION [15.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403. J9 .INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [:12.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER [13.PARTNERSHIP [17.FEDERAL AGENCY- <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation 495. •H 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 /> ❑Yes J"Jo <br /> 1I. PROPERTY OWNER.INFORMATION <br /> PROPERTY OWNER NAME1 407 PHONE <br /> lwaK . <br /> et'to ls ,;M fho'ro a09 - 131 - 047 <br /> MAILING OR STREET ADDRESS(,OSO <br /> CITY 411, STATE 41L ZIP CODE 412. <br /> S+0C,k+0n CA 1 952),5- <br /> PROPERTY OWNER TYPE Ll 1.CORPORATION ff2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 41 <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME414_ PHONE 415. <br /> Same, as Pro ,+. Oc...1/le r <br /> MAILING OR STREET ADDRES91 416. <br /> CITY 417. 1 STATE 419. ZIP CODE Co. <br /> TANK OWNER TYPE El 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCYIDISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK)HQ 44- 1 1 1 1 1 1 Call(916) 322-9669 if questions arise 421_ <br /> V.PETROLEUM.UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑I.SELF-INSURED ❑4.SURETY BOND ❑T STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> [32.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER [199.OTHER. 472 <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> 'VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifiwtums and mailing. <br /> Legal notification ark mailings will be scram the tank owner unless box I m 2 is checked. ❑ L FACILITY jff2. PROPERTY O WNER ❑1 TANK OWNER 423. <br /> VIL APPLICANT SIGNATURE <br /> CaniScarun: 1 certify that the information provided herein is we and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICAQfT DATE 424PHONE 40. <br /> /D na oz OZO 931- 0971 <br /> NAME O APPLICANT(print) 426 TITLE OF APPL CANT 4W. <br /> ck,4 5W, o+o ownar <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency ase omy) 4N. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99).U2 http://www.unidocs.org Rev.02116/00 <br />