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UNIFIED PROGRAM CONSOLIDATED FORM O` <br /> \L0\ TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY ,50.,Op ��t�yl <br /> (one page per site) Pap- f_ <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMITS.CHANGE OF MFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> ale man n only) ❑4.AMENDED PERMIT change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEb1PORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINFSSNAME(s®e.FACRrrveur, -. -D-:s ...A.) z FACILrrYID1l I <br /> // <br /> b <br /> NEAREST CROSS STREET at FACILITY OWNER TYPE - 4.LOCAL AGENCY/DIS CT• <br /> Q� 1�urC/},'/?x W1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS 1.GAS STATION 3.F 5. COMMERCIAL [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRE3UTOR ❑4.PROCESSOR❑6. OTHER 402 ❑ 3.PARTNERSHIP [17.FEDERAL AGENCY* 4a2 <br /> TOTAL NUMBER OF TANKS IS facility on Indian Re.Sayatim or •If owner of UST is a public agency:more of supervisor of division,section or office which <br /> REMAINING AT SITE tnutlands7 operates the UST(This is the contact person for the tank records.) <br /> 4a ❑ Yes ❑ No 405 .a <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4a7 &-?/I- D 4011 <br /> V <br /> MAILP VQRS ADL�.E�S! 4011 <br /> CITY Oto 1 STATEOtt ZIP CODE 212 <br /> i¢ �D <br /> PROPERTY OWNER TYPE .CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT U6.STATEAGENCY <br /> L]3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 Pq0N2E 415 <br /> QdQ <br /> M IN ES <br /> O ADDRS Ota <br /> CITY t 4t9 STATE Ota ZIPCODE!&962- <br /> ^ ' 2- 419 <br /> TANK OWNER TYPE .CORPORATION 2.INDIVIDUAL 4. AL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> 3.PARTNERSHIP rl 5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K H D 1A I Call 916 322-9669 if questions arise 42l <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILrrj( <br /> INDICATE METHOD(S)l.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM <br /> ❑ .GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 4zz <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box in indicate which address should be used for legal notifications and mailin& <br /> Legal notifications and mailings will be sem to the tams owner unless box 1 or 2 is clacked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-1 certify that the information provided herein is true and accurate to the bat of my knowledge. <br /> SI4NA OF PLICANT DATE j�]/E//I '�L/ <br /> Z -/0/ 414 P �-/J�/✓ 3 <br /> NAME PL ANT(print) 426 TRLE;QF APPLIC en <br /> r <br /> STATE UST FACILITY NUMBER(Fa Imt ass osly) 428 1998 UPGRADE CERTIFICATE NUMBER(For lural err.4aly) 429 <br /> UPCF(1/99 revised) L 8 1-4 Formerly SWRCB Form A <br />