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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - FACILITY TANKS- (one page per site) Page TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION % ].PERMANENTLY CLOSEDS (Check arc rues only) ❑4.AMENDED PERMIT specify change local use only .TANK REMOVED �J ❑6.TEMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION I BUSINESS NAME(sar uFACT1lrY J �-Dasg 9ararAa) 7 FACILJTYID11 llC NEAREV CROSS STREET 401 FACILITY OWNER TYPE U 4.LOCAL AGENCY/DISTRICT- A-21-ft- GENCY/DISTRIC- 3S/8 E 4 n S 1.CORPORATION ❑5.COUNTY AGENCY' BUSINESS W.GAS STATION U 3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation m elf owner of UST is a public agency:more of supervisor of division,section or office which REMAINING AT SITE tnacdands7 operates the UST(This o tM contact person for the tank records.) 4aI ❑ Yes ❑ No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME � 7d 4a7 � �U 2� 4108 LIN ADDRESS (J 40 OX CRY r ^ Ota STATE Ott ZIP CODE AC) . `2 412 PROPERTY OWNER TYPE I.CORPORATION U2ANDFVIDUAL Lj 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY ❑3.PARTNERSHIP ❑S.COUNTY AGENCY [17.FEDERAL AGENCY 413 III. TANK OWNER INFORMATION TANK OWNER Ahs _ 414 1 P NE 415 I MAILING OR STP/`' V//AFESS 46a(fx 0 4F6 CITY e to STATE 14ts ZBs CODE ^O �y 419 t (� r- TANK OWNER TYPE 1,CORPORATION Lj 2.INDIVIDUAL 4.LOCAL A /DISTRICT U G STATE AGENCY na 3.PARTNERSHIP El 5.COUNTY AGENCY 7.FEDERAL AGENCY FV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY HQ 44- Call 916 322-9669 if questions arise 421 V. PETROLELirI UST FINANCIAL RESPONSIBILIT`l( INDICATE METHOD(s) L{L SELF-INSURED ❑4.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 132 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check am box to indicate which address should be rued for legal notifications and mailing. Lcgal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER 3.TANK OWNER 4n VII. APPLICANT SIGNATURE Cnnilietuion 1 'fy,that the information provided herein u true and accurst:to the best of my knowledge. SIGNA F PLICAN DATE424 P NE 425 11117-101 i NAME OF APPLTCANT(print) 426 TITLE 9E APPLICANT, m STATE UST FACILITY NUMBER(For lonat.w only) 418 1998 UPGRADE CERTIFICATE NUMBER(gar bat only) 429 UPCF(1/99 revised) �.w 8 Formerly SWRCB Form A