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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> ae s4e <br /> Page _ d <br /> TYPE OF ACT10N O I NEW SITE PERMIT O ].RENEWAL PERMR O w 5.C GE OF WFORMATION(SPec/y rA t- 11AN <br /> J ERMENTLY CLOSED SITE <br /> (CnefAone 9errl curl <br /> ❑ ..AMENDED PEAMR bcY vu°M7) 6.TANK REMOVED am <br /> O S TEMPORARY SDE CLOSURE <br /> 3 = I.FACIL['fYi SfTE INFORMATION s,si� :.: y�? x�' <br /> �USWESS NAME(Same aA FACILrTY NAME a DCA-Do 0e oe bels Aa) 3 FACSDYA4 I Uxz g ({ <br /> 1h1C��}�UCA1C _ _ 6 * "� 2 >xl <br /> INFMESTCROSSSTR-�E-1LT 101 F ARYL RATgNE - ❑ a. LOCALAGENCYMMTAICr i <br /> I L/\a,�/OOUwI 0111 WwOMWAI S. GATEASECr <br /> I fiUS0iE55 � 1 GAS STATION ❑SFARM S.COMMEACW. ❑ 6. STATE AGENCY' <br /> TYPE O 3. PARTNERSI9P O 7 FEDE0.ALAGENCY' 103 <br /> ❑2.DISTRIBUTOR ❑<.PROCESSOR ❑ S.OTHER 103 <br /> TOTAL NWB ER OF TANKS I I.Wftym WmnResa atio0a 'K Ovmer of USTkaP<tlic a9ercY sumeMNlRarvka or <br /> REMAINING AT SITE I mauz.5s't Q,Wm sewan a 0.r1iMI9 F".Pr UST. <br /> � DT•a k 1M cvraatl Mrton lar M rrA IemrOs I <br /> ❑Yes ON, 105 <br /> II.PROPERTY OWNER INFORMATION - <br /> - <br /> ( MAL91G STREET E S 'd z d l S v i T \ 409 i <br /> ISSTATER 1tt PCOOE <iJ1 gL4�/Y 1t3 <br /> PROPERTY OWNER TYPE ❑ 3. INOMOVN- O l LOCAL AGENCY/DISTRICT C16. STATEAGENCY 413 <br /> Of t CORPOPATKKI <br /> I O 3. PARTNERSHIP 115.COUNTYAGENCY O 7. FEDERALAGENCY <br /> III.TANK OWNERINFORMATION -..� <br /> TANK VMERNAME 414 164ONE <br /> _ 3�►-309 - <br /> 416 <br /> S 113 STATE 118 LP CODE ^ Q3 tl9 <br /> !! <br /> TANK ONWERTYPE � O 2 INDMDU O 4, LOCA.AGENCWDIISSTRK:T [16- STATE AGENCY 130 <br /> lN�i. CORPORATION O 3. PARTNERSHIP O 5. COUNTYAGENCY O 7. FEDERALAGENCY <br /> W.BOARD OF EQUALIZATION LIST STORAGE FEEACCOUNTIIUMBER <br /> TY(TK)HQ 4 d I --_Gall(91G)322-9669 8 pues6ons arise 431 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY' <br /> INDICATE METNOD(SI O 1 SELF-INSURED O 4. SURETYBONO O 7. STATE FUND ❑ W. LOCALGGVTMECHANSM <br /> O❑ 2 GUARANTEE O 5, LETTER OF CREW O 6. STATE FUND a CFO LETTER ❑99. OTNER <br /> QY3 INSURANCE 116. EXEMPTION O9 STATE FVHO 6 CO 4n <br /> r eszc l^ <br /> VI.LEGiw§° TIFICATION AND MAILING ADDRESS -,� <br /> Cre a,.W.u wrn..nq,aaxaas a++o<:u x lcea ra Iron IYaS(Kltiaal w Ivuq. <br /> Legal�Sans W m Yqs vNi M as-1 b M IaNc o+ner Weu pa 1 a 2 k nMO:M 0 f. FACrtfTY UK, PROPERTY OYMER ❑ ] TINKOKNER 42J i <br /> VII.APPLICANT SIGNATURE <br /> I <br /> CeNcaSac lcanM P�atce' kfiue v:eamrale to 0<e EasldmY t+ww4E9a. i <br /> SI NAI-R,A,T W A. A24 V 1925 <br /> NAMml , <br /> LKN:ANf t <br /> 126 AF 137 i <br /> i iL-K �EN <br /> STATEUSTFACILITYNVMRER(Faar+Ias .W -- Q$ 19%UPGRADE CERTIFICATE NUMBER(Fa,G'JI N3G aRY1-- 429 <br /> I <br /> UPCF(1199 revised) 5 ForroeAy SWRCB Fom A <br />