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3 rz <br /> UNIFIED PROGRAM CONSOLIDATED FORM / 1 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY �1 <br /> (One page per site) Page L of r <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT Cl 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Cbmk one have only) [14.AMM409D PERMIT (Spmify change) _;XS.TANK REMOVED <br /> C^ ❑6.TEMPORARY SITE CLOSURE <br /> L ..FACILFEVISI".EE:- :tel a e Fgd a : p, <br /> BUSINESSNAME(smQQ.�F1A_c is NAa4Eor -omao.m) 3. FACILITY <br /> Rot 1 el(!N C at'r ID# D / <br /> NEAREST CROSS STREET ,,rr sol. FACILITY OWNER TYPE 4.LOCAs.AGENCYA:HSMCI'* <br /> /J +� <br /> 5II COMMERCIAL ^�- ❑1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS 1.GAS STATION 3.FARM 5. 0.2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY- <br /> TOTAL NUMBER OF TANKS 404- G facility on lndim Rucvetion 446- 'H owner of UST isa public agency:mm of supervisor of division.aecdoo or sob. <br /> REMAINING AT SITE or trust lands? office which operate,the UST. (This is the conuntpeuoa for the took records.) <br /> El Yes -ilTo <br /> ss...a sI. x <br /> J. t, <br /> :..PROPERTY OWNER NAME <br /> PHONE <br /> Ke TO aoa <br /> a09 - 13I - o 1- r <br /> MAMJNG OR STREET ADDRESS 4gq_ <br /> .L (,OSS Gain;cw GT <br /> CITY S+0 G r-+-o r\ 410. STATEC f 411- ZM CODE_,_,,.s 41Z <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.1NDIVIDUAL 4.LOCAL AGENCY/DISTRICT r� LJ6.STATEAGENCY 41T- <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> 77 <br /> TANK OWNER NAME... 11 'p. .. _._. a4. PHONE ali . <br /> SGML cLS ` f0 ,+� Oc.,J0e r- <br /> MAILING OR STREET ADDRESSR 416. <br /> CITY 417. STATE 419. 1 ZIP CODE 419. <br /> TANK OWNER TYPE 0 1.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT [:16.STATE AGENCY neo. <br /> ❑3.PARTNERSHIP S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION#S`F`'G41Yt1'kv3il E ACCOUNT NL-nBER <br /> TY(TK)HQ 44- 1 1 Call 916):2'-9(169 it questions ansc ,ori- <br /> V.PETROLEUIDF. EI4FSIBILI"I'Y <br /> INDICATE METHOD(s) ❑I.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM a22 <br /> ❑2.GUARANTEE ❑5.LEITER OF CREDIT ❑a.STATE FUND&CFO LEITER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> NAND - <br /> .i' <br /> Check one box to mdcam which address should be and for legal notifimlim and mailing. <br /> Legal notifications and mailings will be scut to the us k owner unleat box I w 2 is checked ❑ I.FACILITY 2. PROPERTY OWNER ❑3.TANK OWNER <br /> SIGNATURE, IM <br /> > ° 3�t"-�,aFgss <br /> =ion I certify that the infarm um provided heroin is true and aenuete m the beat of my komitmi c- <br /> SIGNATURE OF APPLIC DATE PHONE 4� <br /> /Osr/a oz o1o9- 931- 097/ <br /> NAME O APPLICANT(prim) 42b. TITLE OF APPLICANT 6Y1- <br /> ct 4 5W. o+o o wna(- <br /> STATE UST FACILITY NIUMBER(A9my a.e mly) +r% 1998 UPGRADE CERTIFICATE NUM13ER(A9ema'm m>) 4�- <br /> (See Data Element 1,above. <br /> UPCF Hwft w (1/99)-112 http:/Mw r unido "ll Rev.02116100 <br />