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UNIFIED PROGRAM CONSOLIDATED FO <br />UNDERGROUND STORAGE TANKS - FACILITY <br />TANKS <br />(one page per site) <br />Page _ o/ _ <br />TYPE OF ACTION r 1, NEW SITE PERMIT r 3. RENEWAL PERMIT r 5. CHANGE OF INFORMATION (Specify change- r 7. PERMANENTLY CLOSED SITE <br />(Check one item only) 4. AMENDED PERMIT local use on r 8. TANK REMOVED 400 <br />r <br />F fi. TEMPORARY SITE CLOSURE - <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 <br />0P 0 <br />FACILITY ID If <br />FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br />IYQ. CORPORATION r 5. COUNTYAGENCY` <br />r 2. INDIVIDUAL <br />r 8. STATE AGENCY• <br />r 3 PARTNERSHIP <br />r 7. FEDERAL AGENCY' 402 <br />NEAREST CROSS STREET 401 <br />BUSINESS TYPE GAS STATION r 3. FARM r 5. COMMERCIAL <br />r 2. DISTRIBUTOR r 4. PROCESSOR r 6. OTHER <br />403 <br />TOTAL NUMBER OF TANKSIs <br />REMAINING AT SITE <br />404 <br />reality on Indian Reservation or 'if owner of UST is a public agency: name of supervisor of <br />trustlands7 division, section or office which operates the UST. <br />(This is the contact person for the tank records.) <br />r Yes Vzo 405 403 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />Ower Pok <br />PHONE 408 <br />MQ) acts <br />MAILING OR STREET ADDRESS 409 <br />i i4f o,n Mid,c IGSo <br />CITY 410 <br />Co <br />STATE 411ZIP <br />6 <br />CODE 412. <br />08oa <br />PROPERTY OWNER TYPE v r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br />-LCORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r.7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />Owt� Filer 6rou <br />PHONE 415 <br />C�Gz� -YaaS <br />MAILING OR STREET ADDRES/� 41�II��O <br />CITY 417 <br />o Be L, <br />STATE 416 <br />21P CODE 419 <br />o?0a <br />TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 ' <br />CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERAL AGENCY <br />IV <br />TY (TK) HQ 4 4 1 - 3 <br />IBQAgnnFFOIIAI17AncuitsLs:ce)gArFFFFArrniiNTNIIMRF:R <br />Call (916) 322-9669 if questions arise 421 <br />INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=TMECHANISM <br />F 2. GUARANTEE r S. LETTER OF CREDIT STATE FUND 8 CFO LETTER r 99. OTHER <br />F 3. INSURANCE r 6. EXEMPTION 9 STATE FUND 8 CD 422 <br />Check one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 923 <br />Le al notifications and mailin s will be sent to the tank own net unless box 1 or 2 is checked <br />Certification, I certify that the information provided herein is hue and accurate to the best of my knowledge. <br />SIGNATURE OF APPLICANTT Y <br />DATE ' ' t' 00 424 <br />PHONE 425 <br />3s -yaws <br />NAME OF APPLICANT (Print) Q , 426 <br />r Cf e <br />TITLE 0F� L T 427 <br />, s� <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />