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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (` -(one page per slte) <br /> Page J_ of <br /> TYPE OF ACTION r 1.NEW SITE PERMIT �3.RENEWAL PERMIT I� 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) I� local use only) r 8.TANK REMOVED 400 4.AMENDED PERMIT <br /> 16.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID M <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE h 4. LOCAL AGENCY/DISTRICT' <br /> X1. CORPORATION <br /> 5. COUNTY AGENCY' <br /> BUSINESS TYPE I- 1.GAS STATION I' 3.FARM I, 5.COMMERCIAL I' 2. INDIVIDUAL <br /> I 6 STATE AGENCY' <br /> I� 2.DISTRIBUTOR I, 4.PROCESSOR X6.OTHER r 3. PARTNERSHIP I' 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 r Yes )eN0 405 406 <br /> Ill.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> S7-SE2y/GFS 97,7, <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> S 7sz S <br /> PROPERTY OWNER TYPE �,/ I� 2. INDIVIDUAL I' 4. LOCAL AGENCY/DISTRICT I` 6. STATE AGENCY 413 <br /> IR 1. CORPORATION r 3. PARTNERSHIP I- 5. COUNTY AGENCY h 7. FEDERAL AGENCY <br /> V` III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> T Iii(_c-S <br /> MAILING OR STREET ADDRESS 416 <br /> �9y1 N9ey GSR <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> s7Dc-,lTo/L/ c� 9520& <br /> TANK OWNER TYPE 2. INDIVIDUAL I 4. LOCAL AGENCY/DISTRICT I�6. STATE AGENCY 420 <br /> 1. CORPORATION r 3. PARTNERSHIP I- 5. COUNTY AGENCY h 7 FEDERAL AGENCY <br /> TY(TK)HQ 4 1 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) K, SELF-INSURED IF 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> I 2. GUARANTEE IF 5. LETTER OF CREDIT I 8. STATE FUND&CFO LETTER I 99. OTHER <br /> I` 3. INSURANCE IF 6. EXEMPTION I� 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal nolocations and mailing. r 1. FACILITY F 2. PROPERTY OWNER 3. TANK OWNER 423 <br /> Le al nolifiwlions and mailin swill a sent to the tank owner unless box 1 or is ecked. <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE _ 424 1 PH N,E425 Y0o <br /> NAKf qo,F APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> LC" ✓ uLL n/S /rlla2- v/R. C/y�77{ � � <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> l <br /> UPCF(1/99 revised) 5 c�Formerly SWRCB Form A <br />