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�i��oo�3375 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page persite) <br /> Pa _ o/ _ <br /> TYPE OF them on P/1 NNEW SITE PERMIT ]'3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION Speclty,change- r 7 PERMANENTLY CLOSED SITE � (\,Q\ <br /> (Check one item only) ! T' 4.AMENDEDPERMIT local use only) ( uK REMOVED 900 <br /> r 6.TEMPORARY SITE CLOSURE 9 <br /> I.FACILITY I SITE INFORMATION <br /> BUSINE <br /> ,,SS NAME(S ACILITY NAME w DBA-D 'np Buainesa As) 3 FACILITY ID S <br /> l <br /> NEAR T SSS EJ 401 FACILITY OWNER TYPE j' 4. LOC AL AG NC <br /> r 1 CORPORATION r S. COUNTY AGENCY' <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM r 5.COMMERCIAL 2. INDIVIDUAL <br /> r 6 STATE AGENCY' <br /> r 2 DISTRIBUTOR r 4 PR OR OTHER TNERSHIP ) L FEDERALAGENCY• 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility an hldun Reservation or 9f owner of Ume <br /> ST is a public agency:naof supervisor of <br /> REMAINING AT SITE humlands7 division.section or office which operates the UT. <br /> S <br /> (Thu is the contact person for the tank records.) <br /> 404 Ore— rYes 405 4W <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY l{AME 407 PHO Zb <br /> _I(`J a <br /> III OR ST TADDRESS 4_09 <br /> CITY 410 �`�"`''I�ij STAT ZIP 412 <br /> PROPERTY OWNER TYPE INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6 STATEAGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY 1- 7 FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK O ER E 414 ( PHO 41 V <br /> MAILINGORSTREET DRESS 41fi <br /> I SsCI 917 SIATE ZIPCODE 919 <br /> TANK OWNER TYPE 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> ]' 1. CORPORATION ]' 3. PARTNERSHIP r 5. COUNTYAGENOY r 7. FEDERAL AGENCY <br /> �TY(TK)HO 4 4 1 - I I I I Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOO(S) r 1, SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=TMECHANISM <br /> r 2 GUARANTEELETTER OF CREDIT I' 8. STATE FUND d CFO LETTER r 99 OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9 STATE FUND&CD 422 <br /> Check one box to st icate which address shook be used fw bpal rrot8kations end meilinp. r 1. FACILITY r 2. PROPERTY OWNER r 3 TANK OWNER 423 <br /> L al nolRkalians and maili s it n the t n unless x 1 or is <br /> Certification: 1 cert4y that the mfonnabon provided herein ie hue ark acaaate to tha best of my knowledge. <br /> SIDATE V <br /> G <br /> NAME OF P I (pn PHONE 425 <br /> CX O( <br /> 447 <br /> 4261 TITLE <br /> 427 <br /> STATE UST FACILITY NUMBER(Fix tical use only) 428 1998 UPGRADE CE'RTIF ICATE NUMBER(For)ocatu�seQonly) 429 <br /> �For <br /> UPCF(1/99 revised) 5 v_� ( _ 0 1 6 ` Formerly SWRCB Fq <br /> V vow,* <br />