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MAY-20-2005 11 :32 AM RAH ENVIRONMENTAL INC 916 652 8955 SQ P. 02 <br /> - Z3-O51 <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1011 <br /> ©l"J TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per Site) Page_of_ <br /> TYPE OF ACTION ❑ 1.NEw SITE PERMIT ❑3.RENEWAL PERMIT COS.CNANGE OF INFORMATION �❑a{ ).PERMANENTLY CLOSED SITE(Check one itemo.10 [34.AMENDED PERMIT specify change local use only /X S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE •� <br /> I. FACILITY/SITE INFORMATION <br /> BUSNESSNAMEIS. PAC oeA-DonaFl.. ,(, x FACILITY IDM �� <br /> ee '-J/jG o n 4 C. <br /> i OSS 0 ��r s •ol FACILITY OWNER TYPE 4.LOCAL AGENCY*TRIC)• <br /> N A CROSS <br /> 7aSN.t:� i��Ylc '❑ 1.CORPORATION ❑s.couNTvnGENcr <br /> BUSINESS I.GAS STATION 3.FARM S. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR 6. OTHER 4o3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' mx <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or alfow¢r of UST is a public agency:mmeohtger isarofdivision,seednn oroRice which <br /> REMAINING AT SITE wdandsx I opemm Me UST(This is the camas[person for the tank recotda.) <br /> 6�V .os ❑ Yes No 4ow 404 <br /> IL PROPERTY OWNER INFORMATION <br /> P P R 01 PHONE 409 <br /> t � &ye,470 <br /> -alaf -29 <br /> MAIL RSTREETA DRESS _ s0° <br /> /.� <br /> Sm <br /> 5 <br /> CITY UO STATE •" ZIP CODE 7520 •ix <br /> % <br /> I PL <br /> PROPERTY <br /> ONE TYPE I.CORPORATION El 2.INDIVIDUAL K4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> ❑3.PARTNERSHIP CIS.COUNTY AGENCY [17.FEDERAL AGENCY •'s <br /> III.TANK OWNER INFORMATION <br /> TANK O ER y�M ,Q aia PHONE _ us <br /> Mpt a r `� 1��1� /OZl <br /> U6 <br /> - 4W <br /> MAILN R STRE T AD 1 1 <br /> 72 S <br /> CITY 417 STATE 411 21P CODE o 419 <br /> OCO <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DLSTRICT LJ6.STATEAGENCY Oxo <br /> }.PARTNERSHIP ❑5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44- 1 1 1 1 Call 916 322.9669 if questions arise •x' <br /> 7 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOO(S) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND 10.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE [15.LETTER OF CREDIT ❑a.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 'ss <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check om boa b iMkate which address SbWld be bed for Icpl naificatiom and mailing. <br /> Legal eatif¢atiom and mailinp will basest to the ask ownarwlesf bon I or 2 is checked ❑ I.FACILITY C3 Z- PROPERTY OWNER C3 3.TANK OWNER 4D <br /> I <br /> VII.APPLICANT SIGNATURE R 0030 <br /> Cmifkaslun-I certify[tit infamomn tovided heroin is ove and accioate b th<besr ofrtry knowhnge. <br /> A F / sxa <br /> SIG PCANT 4 <br /> DATE PH µ i 9✓ 7- 9 <br /> NAK9 OF 6,PPLJqANT(print) 436 TIT E4Q55 APPLI A T 411 <br /> CZ- r G�7k0r et o r <br /> STATE UST FACILITY NU B RlfQ wca we e•Nt 4$9 1998UPGRADECERTI ATENUMBERIFnlmteseoayl 4xw <br /> UPCF(1/99 revised) 171 Formerly SWRCB Form A <br />