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l <br /> UNIFIED PROGRAM CONSOLIDATED FO M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> ----- Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMITz CHANGE OF INFORMATION(Specy change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one dem only) <br /> r 4.AMENDED PERMIT local use only) r S.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> StZ_ ' I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IDs <br /> S1,31 <br /> / I <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCYIDIS ICT• <br /> F 1 CORPORATION r 5J;�6 <br /> COUNTY AGENCY- <br /> SS TYP 1,GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> -�L STATE AGENCY• <br /> r 2.DISTRIBUTOR r 4.PROCESSOR a�OTHER r 3 PARTNERSHIP FEDERAL AGENCY* 402 <br /> _ 403 <br /> TOTAL NUMBER OF TANKS la faolity on Indian Reservation or 'a owner of UST is a Not.egenq:roma o/supervisor of <br /> REMAINING AT SITE _ trusllaMa7 division,section or once which operates Ma UST. <br /> `X/X (This ie the conteC person for the tank records.) D <br /> 404 r Yee 405 406 !Y✓l <br /> It.PROPERTY OWNER INFORMATIONJ <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING STREETADD <br /> 5 ESS 409 ;� p <br /> CITY STATE 411 OOE 4122 <br /> r43- <br /> - 1561Q <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCV 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5 COUNTYAGENCY oe%-fEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> 445 <br /> TANK ER NAME 414 C19 PHOfl�C) '4�3I <br /> MAILING OR STREET,ADDRE�(,JJ SS-, � <br /> CI 3 413 TATE 418 ZIP-CU--- <br /> DE 419 <br /> cag 95a/3 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCYFEDERAL AGENCY <br /> TY(TK)HQ 4 4 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 /> F 2. GUARANTEE r 5. LETTER OF CREDIT r S. STATE FUND&CFO LETTER OTHER: <br /> IF 3 INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> CMGs ons Eos to indicate which address,shouts M used for legal notifications and mailing r 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> al nb' rk ma'f f will t to the tank r unless 1 r i <br /> Co,rcation: I.miry thatme information provided herein is true and accurate to the Mst of my knowledge. <br /> SIGNATURE OF APPLICANT D::� ATE424 PHONE 425 <br /> NAME OF APPLICANT(pMp 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> PR =-�3 151�/' Lo� a3, 660 �, b_Cl 0� <br /> UPCF(1199 revised) Formerly SWRCB Form A <br />