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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION rl-I-NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify chime- r T.PERMANENTLY CLOSED SITE <br /> (Check one item only) local use onr ly) B.TANK REMOVED 400 <br /> new)V (l jscoV&' xl r 4.AMENDED PERMIT <br /> r 6.TEMPORARY SITE CLOSURE rQ <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY 10 R <br /> O <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCALAGENCY/DISTRICT' <br /> r 1. CORPORATION r S. COUNTYAGENCY` <br /> BUSINESS TYPE r 1.GAS STATION r &FARM r S.COMMERCIAL r✓Z INDIVIDUAL <br /> / r 6. STATE AGENCY' <br /> r 2 DISTRIBUTOR r PROCESSOR F 6 OTHER r 3. PARTNERSHIP F 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is/a<ility an Indian Reservation or 'If owner of UST is a public agencyname of supervisor of <br /> REMAINING AT SITE Wstlantls? division,section or office which operates the UST. <br /> 3 (This is the contact person for the tank records) <br /> 404 r Yea tKJo 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 rPHONE 408 I <br /> VInA, <br /> MAILING OR STREET ADDRESS 4 <br /> a r <br /> CITY 670iV STATE A ZIP D <br /> PROPERTY OWNER TYPE (//J 2. INDIVIDUAL F 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> r I. CORPORATION r' 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE 415 <br /> N4 �9-9�{6 -15Sb <br /> MAILING OR STREET ADDRESS 416 <br /> Ccr <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> CA C15a-DG <br /> TANK OWNER TYPE r INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION r' 3 PARTNERSHIP r 5 COUNTYAGENCY r 7 FEDERALAGENCY <br /> TY(TK)HO 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD($) r 1. SELF-INSURED r 4, SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND 8 CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should ba uead for legal notifications and mailing. r 1. FACILITY F72. PROPERTYOWNER r 3. TANKOWNER 423 <br /> Local notifications end mailings will bs sent to the lank pointer unless x 1 or 2 is chocked. <br /> Certification I candy that the information previded herein is We and accurate to the beat of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(Pont) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Forlaca/use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 429 <br /> `1�31(bl <br /> 5 <br /> UPCF(1/99 revised) Formerly <br /> SWRCB Form A <br />