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UNIFIED PROGRAM CONSOLIDATED FORM I O-0 <br /> 7 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> TYPE OF ACTION 0 1 NEW SITE PERMIT Cl 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION(SP fy chap.- 1] 7 PERMANENTLY CLOSED SITE <br /> (Chat orM,AA1r mly) <br /> ❑ d.AMENDED PERMIT anq/ taco/u4e �I 8.TANK REMOVED 400 <br /> / I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Sema«FACILITY NAME a,OBA-D«p Buaina«Aa) 3 FACILITY ID s <br /> . =4 1 <br /> L D� OD^ <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE m� <br /> ❑ 1. CORPORATION /tet 4. LOC147YAG NCYI HILT <br /> y ' ❑ 2. INDIVIDUAL 5. COUNTY AGENCY• <br /> TYPE BUSINESS ❑ 1.OAS STATION , ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 3. PARTNERSHIP [38. STATE AGENCY' <br /> ❑ 7. FEDERAL AGENCY' <br /> 2 DISTRIBUTOR 134.PROCESSOR A8.OTHER 403 402 <br /> TOTAL NUMBER OF TANKSd f 14y an IMwI Raaarvak9h d T o.Vnw a UST a FUWic agency:r-ma a sullanAaa,a <br /> REMAINING AT WutlaMai Eli .saaTan w offm v ieh cpe Cta UST. <br /> .o. Ghia is Me canfact paraan for Iea tank mco,da.) Jo 7 70 <br /> ❑Y« No AM <br /> m PROPERTY OWN ER IN FORMATION <br /> PROPERTY OWNER NAME <br /> MAILING SrREETAODRE 409 <br /> 2z <br /> CRY / 410 STATE 411 ZIP CODE 412 <br /> ��z41/- i o <br /> PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL <br /> d. LOCAL AGENCY/DISTRICT ❑ S. STATE AGENCY 413 <br /> ❑ 1. CORPORATION 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ ]. FEDERAL AGENCY <br /> 1111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> PH; <br /> MAILING OR ADORE 415 <br /> 22 Lr7• 1 <br /> CITY 41] STATE 418 ZIP CODE 419 <br /> 0 -, <br /> TANK OWN TYPE ❑ 2. INOIVIOUAL _IX-4. LOCAL AGENCY/DISTRICT ❑ B. STATE AGENCY AM <br /> ❑ 1. CORPORATION 13 3 PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ Z FEDERAL AGET <br /> N.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO 4 4 Cail(916)322 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHODS) 0 1. SELFJNSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND Cl 10. LOCAL GOVTMECHANISM <br /> ❑ Z GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND 8 CFO LETTER ❑ 99. OTHER_ <br /> ❑ 3. INSURANCE ❑ 8. EXEMPTION ❑ 9. STATE FUND 6 CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS _ <br /> Chock ane IAu b.,Id ta w .h IKIcl s e lcl M is far I"W naifM:afklna AM mLlkp. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ❑ 3. TANK OWNER AM <br /> L4pe1 roaica0om AM malli,pa.al W a t to fha tank ov,rlM unl4 hok 1 m 2 ta chmk4d. <br /> VII.APPLICANT SIGNATURE <br /> Csrafkak9n: 1 CWtfy IMI VIa IMormakan I> eJ he,aw a hw aM=unb W ew D t of my knowWge. <br /> SG RE OF AP1117T DATE 424 PHONE 425 <br /> NAME OF APPLICANT �. 428 Trrl.EOIfAPPUC T yy 427 <br /> Ax ' ' <br /> UPCF(1,99) Fwmrly SWRCB Form A <br />