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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION rf.NEW SITE PERMIT O 3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑ 7.PERMANENfLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑67EMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSIN SNAME(serve as FACILITY NAME or 118A-Doing Business As) FACILITY IDN <br /> { V <br /> N ST CRO STi� 401 FACILITY OWNER TYPE 4.LOCAL AGENCYIDISTRICT" <br /> a� ❑ 1.CORPORATION ❑5,COUNTY AGENCY' <br /> BUSINESS AS STATION U 3.FARM 0 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR[16. OTHER 412 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' an <br /> TOTAL NUMBEROF KS Is facility,on Indian Reservation or olf owner of UST is a public agency:time of supervisor of division,section or office which <br /> REMAINING ATS trustlands? operates the UST Cfhis is the contact person for the took mcords.) <br /> 404 ❑ Yes El-10 405 1 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERT OWNER NAME 4m PHONE 4N <br /> le <br /> r <br /> MAILING OR STRE.Xr ADDRESS 409 <br /> 0 <br /> CY_ Oto STATE 4u ZIP CODE M2 <br /> GTION IAGENCY/ <br /> 9S,Z 2 <br /> PROPERTY OWNER TYPE 1.CORPORAVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STA E AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY [17.FEDERAL AGENCY 40 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS as <br /> CITY 417 STATE Ota 1 ZIP CODE 419 <br /> TANK OWNER TYPE Lj 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 4m <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED [14.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> [13.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one bex la indicate which address should be used for legal notifications end mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked ❑ 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 4D <br /> VII.APPLICANT SIGNATURE <br /> Certification-1 certify that the information raided herein is true and accurate to the best of my knowledge. <br /> SIGNA RE OF A PLI A jFE 411 PHONE �- 425� <br /> NAMEOF APPIC (pr' 426 TITL OF APP (CANT 427 <br /> G <br /> STATE LIST F ILIT Y NUMBER(For iocd ore way) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />