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UNIFIED PROGRAM CONSOLIDATED FORM PIR#: <br /> FAC#: <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) 7 2 lO Z <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOS ITE <br /> (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED .1 D <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION t_ <br /> BUSINESS NAME(S.meu FACILITY NAME or DBA-Doing Busauss As) 3 FACILITY # PR ID# <br /> SSC. mbSNUIVD -F VQCA00_ CTRL- YIb <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT- <br /> 401 <br /> ❑ 1.CORPORATION X 5.COUNTY AGENCY' <br /> BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY- <br /> TYPE [:] DI ❑ 3.PARTNERSHIP 402 <br /> 2. STRIBUTE]OR 4.PROCESSOR ❑b.OTHER 4n3 ❑ 7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'Ifowner of UST is a public agency:name ofsupervisor ofdivision.section or office which operates <br /> REMAINING AT SITE trusllands? rhe UST(This is the contact person for the tank records.) <br /> 404 ❑ Yes ❑ No 495 Ons <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME407 PHONE 409 <br /> SSL /&b SQA-L, 4 vBUv%YL C,�ru_ <br /> MAILING OR STREET ADDRESS 40 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> El 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 4P STATE 411 ZIP CODE 419 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL 1-14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)FIQ 44- 1 Call(916)322-9669 if questions arise 431 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 1:199.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should he used for legal notifications and mailing. ❑ 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and maifing will be send to the lank owner unless box I or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Formwl m only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fw kcal meway) 629 <br /> Is 1998 Compliant? <br /> UPCF(1/99 revised) _ <br /> L/ �` <br />