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UNIFIED PROGRAM CONSOLIDATED FORM /y <br /> TAN <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> __ (one page per <br /> TYPE OF ACTION Page - °f <br /> (Crack one item only) 1.NEW SITE PERMIT r 3.RENEWAL PERMITr S.CHANGE OF INFORMATION(Speaty change- r 7.PERMANENTLY CLOSED SITE <br /> r 4.AMENDED PERMIT local use onlY) r 8 TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Seree as <br /> FACILITY NAME or DBA-Doing Business As) 3 FACILITY to Is <br /> N C.c <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCALAGENCY/DISTRICT' <br /> r 1. CORPORATION r 5. COUNTY AGENCY' <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM \ r S.COMMERCIAL 2 INDIVIDUAL r e <br /> r 2 DISTRIBUTOR r 4 PROCESSOR �If 6.OTHER r 3 PARTNERSHIP . STATEAGENCY• <br /> F]. FEDERALAGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility an Indian Reservnion or If owner of UST is a public agency name of supervisor of <br /> REMAININGP SITE i trustlands7 division,section or office which operates,the UST. <br /> \- (This is the contact person for the tank records.) <br /> 404 rYes 'VNo 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> cJ4'V M b L LF),.j 0( zo <br /> MAILING OR UTREET ADDR SS 409 <br /> CITYIST_ �- <br /> 470 STATE 411 IP 412 <br /> 11-Hc1� Cllr 4 5 3Zco <br /> PROPERTY OVMER TYPE 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7 FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> CFtcc_ l(_. MU L.1.1t <br /> MAILING OR STREET ADDRESS �s41�6 <br /> J' St <br /> CITY 41 SATE 418 ZIP CODE 419 <br /> E �raJ S c� <br /> TANK OWNER TYPE 2. 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)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 S. LETTER OF CREDIT r 8. STATE FUND d CFO LETTER r 99. OTHER. <br /> r 3. INSURANCE r 6. EXEMPTION r 9 STATE FUND 8 CD 422 <br /> Check one box to irMkste which address elroukl he used for egsl notifications and mailing. r 1. FACILITY r 2. PROPERTYOWNER r 3. TANK OWNER 423 <br /> Legal notlbraticne and m0=1=1119.1,'I o th tank box 1 or ad. <br /> Certification: I certify that he information proyided herein is Wa and eoavate to the heel of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Forfoeel use onty) 428 1998 UPGRADE CERTIFICATE NUMBER(For focal use only) 4129 <br /> 5 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />