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Aft .11111111h. UNDERGROUND STORAGE TAN S FACILITY UNIFIED PROGRAM CONSOLIDATED FORM FFRESNOCOUNTY HUMAN SERVICES SYSTEM-DEPARTMENT OF COMMUNITY HEALTH-ENVIRONMENTAL HEALTH SYSTEM 1221 Fulton Mall, Post Office Box 11867, Fresno, California 93775(559)445-3271 one oaceoer site) Page _ of TYPE OF ACTION ❑ t NEW SITE PERMIT ❑ 3.RENEWAL PERMIT El 5.CHANGE OF INFORMATION(Specify change- ❑ 7.yPERMANENTLY CLOSED SITE (Check one item only) I,i„d/ ❑ 4.AMENDED PERMIT local use only) 8.TANK REMOVED 400 ❑ 6.TEMPORARY SITE CLOSURE L FACILITY I SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DaA-Doing Business As) 3 FACILITY ID# t NEAREST CROSS STREET 401 FACI�1TY OWNER TYPE= ❑ 4. LOCAL AGENCYIDISTRICT' r t CORPORATION ❑ 5. COUNTY AGENCY J 1 � i � f + '-,"- �1 �`'� ❑ 2. INDIVIDUAL BUSINESS ❑ 1 GAS STATION ❑ 3.FARM 5.COMMERCIAL Q 3. PARTNERSHIP ❑ 6. STATEAGENCY' TYPE ❑ 7. FEDERALAGENCY' 402 ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 TOTAL NUMBER OF TANKS Is facility on Indian Reservation of 'If owner of UST a public agency:name of supervisor of REMAINING AT SITE trusttands7 division,section or office which operates the UST. (This is the contact person for the tank records.) 404 Yes L�'Na 405 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 MAILING OR STREET ADDRESS 409 C,1 r L CITY 410 STATE 411 ZIP D� 412 -- - C - L �X0`7 PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY f DISTRICT ❑ 6. STATE AGENCY 413 LJ't. CORPORATION Q 3. PARTNERSHIP ❑ 5_ COUNTY AGENCY ❑ 7. FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME • 414 PHONE 415 E) JA tJ i l'Ar - MAILING OR STREET ADDRESS416 I �1 CITY 417 STA 418 ZIP COj3Ej, 4i9 nuc I-�3:J E ('(j TANK OWNER TYPE / ❑ 2. INDIVIDUAL ❑ 4, LOCAL AGENCY I DISTRICT ❑ 6. STATE AGENCY 420 LJ 1. CORPORATION ❑ 3 PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7, FEDERAL AGENCY IV.130ARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK421 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOO(S) Q 1 SELF-INSURED ❑ 4. SURETY BOND 7. STATE FUND ❑ 10- LOCAL GOVT MECHANISM ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND&CFO LETTER ❑ 99. OTHER: 113. INSURANCE El 6. EXEMPTION ❑ 9. STATE FUND&CID 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. 'Q 1. FACILITY 2. PROPERTY OWNER ❑ 3. TANK OWNER 423 Legal notifications and mailings wiil be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification; I certify that the informs" ided herein is true and accurate to the best of my knowledge, SIGNATURE OF APPLICANT ' a 1 DATE /0� 424 PHONE '35,A25 NAME OF APPLICANT{print} 426 TITLE OF APPL ANT 427 STATE UST FACILITY NUMBER(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For focal use only) 429 HSS-1019 UPCF(4199) FICUPAIFORMSIUSTFRM0I.WPT Formerly SWR.CB Farm A