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UNIFIED PROGRAM CONSOLIOAT-) FORM <br /> 7 l \ <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS <br /> Psaa _ of _ <br /> TYPE OF ACTION 0 1 NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION(Specify chaNs- ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check ora,Mn onw ,rn <br /> ❑ 4.AMENDED PERMIT h7 Ideal user p 8.TANK REMOVED <br /> On <br /> d00 <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Sams as FACILITY NAME or DBA-Dom9 eumnaas As) 3 FACILITY ID 0 1 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE <br /> 13 1. CORPORATION Aa. LOCALT <br /> IOISTRIC <br /> N [38. COUNTYAGIENY' <br /> Y AGENC <br /> [3 2 INDIVIDUAL <br /> TYPE <br /> Y <br /> BUSINESS 13 1 GAS STATION 1 ❑ 3.FARM ❑ 5.COMMERCIAL 13 3. PARTNERSHIP 7, [30. STATE AGENCY' <br /> ❑ 2 DISTRIBUTOR [34.PROCESSOR All.OTHER 403 ,3a IIO s• [3 7. FEDERAL AGENCY• 402 <br /> TOTAL NUMBER OF TANKS h aalky ere Ind'un RssemEon err '8 ovular d UST a public a9aricy.name d wpaMsor d <br /> REMAINING ATmWlaiw <br /> Slily nda? dien.fawhich ctIon or of" opaatn Ms UST. _/ <br /> 1 ❑Yw AN. <br /> (Din is fM cmact Person for Ms tank ramNs.) JO 4//1 WO <br /> 408 <br /> :. 405 <br /> IL PROPERTYOWNER INFORMATION <br /> PROPERTY OWNER NAME 4O7 PHONE 408 <br /> MAIUNG STREET AODR 409 <br /> 2z1 � . <br /> crrY / <br /> 410 STATE an ZIP CODE lu <br /> PROPERTY OWNER TYPE 0 2 INDIVIDUAL 4. LOCAL AGENCY I DISTRICT ❑ 0. STATE AGENCY 413 <br /> ❑ 1. CORPORATION [3 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERALAGENGY <br /> -� - RL TANK OWNER INFORMATION <br /> TANK <br /> OWNER NAME _ 414 PHONE _.. 415 <br /> // <br /> 418 <br /> 221 Lr7• l <br /> PITY 417 STA 418 DP CODE 419 <br /> T r <br /> C K OWN TYPE ❑ 2 INDIVIDUAL W-4. LOCAL AGENCY I DISTRICT ❑ 8. STATEAGENcy 420 <br /> ❑ 1. CORPORATION 13 3. PARTNERSHIP ❑ S. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIQ HO 4 4 Call(916)322-96M if questions arse 421 <br /> - - - V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOO(S) Cl 1 SELFJNSURED ❑ 4. SURETY BOND ❑ 7. STATE FUNO ❑ 10. LOCAL GOVT MECHANISM <br /> ❑ 2 GUMANTEE ❑ 5. LEITER OF CREDIT ❑ 0. STATE FUND 8 CFO LETTER ❑ N. OTHER: <br /> ❑ 3. INSURANCE ❑ 8. EXEMPTION ❑ 9. STATE FUNO 8 CD 422 <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chock=aE aiMcaa whichaddress atcuM W usN for ls9al nWiCaanna and madir19. ❑ 1. FACILITY 13 2 PROPERTY OWNER ❑ 3. TANKOWNER 423 <br /> Lxpl no011oEom aM mailin9a wiN W sant a M bnk owMr unbsa Goa 1 err 2 is chwkad. <br /> VII.APPLICANT SIGNATURE <br /> Carlini wn 1 carefy tM IM idomaUon pauidN hash b bus aIa attuna a Ma Wert d mY knovled9s. <br /> SIGNA E OFA PUCANT DATE 424 PHONE 425 <br /> L:r, 13 /.)-"o <br /> NAME OF ANT(prm0 420 TIRE OF PPLIC T 421 <br /> u� .v l r-- F-6(L OtAiQ <br /> UPCF(15B) FGnn4Kly SWRCB Form A <br />