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APR-04-2007 10 : 38 PM P, 03 <br /> UNIFIED PROGRAM coNSOLIDATED FORM TANKS " <br /> UNDERGROUND STORAGE TANKS -FACILITY <br /> (Onepagepervite) Page-of <br /> TYPE CDON ❑ I.NGW SITE PP2tM1T 3.RENEWAL PERMIT CHANCE OFINPORI.MflC [] ].PERMANFNTIV(LOSED SRF. <br /> OP A <br /> ((bekw ZON,y') ❑4.AMENUED PFRMI'I' sPxlN ehw05•IoeY use^NIY ❑ B.TANK REMOVED <br /> O 6 TP.MPORARY SITE CWSURP. <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sewcu FACILm'NAMcm PHA.-I).ied PaevsAs) a PACILITYIDs I <br /> 1 v <br /> EQr'�'11 I FACILITY OWNTYPE 4.LOCAL AGENCYIDISTRICT• <br /> NI!ARES'1'CR Sam Lf q(A I U'A'11 ER Q 1,CORPORATION O S,COW Y AGENCY' <br /> 2l�s� mA�iC+ L <br /> HUSINIiS4 1.GAS STAn1N 3.FAR 5. COMMEAC AL 2.INDIVIDUAL ❑6,STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR (]4.PROCESSOR❑6. OTHER As ❑ 3 PARTNERSHIP [']7.F'6DERAI.AOIRJL`Y• nR <br /> TOTAL NUMBER OF'1'ANKS Is CxilltymItdwn Resarvmion or •Ifowmrof UJ'ffisnryu Nul:capeney.nmuuuf.upervuoreFA".bn,.Neona +N� <br /> REMAINING AT SI I'S trusdsIds? Weseles Ne USfffhiais Necmnm perP.n fm We mnkrmeds.) <br /> jf xm ❑ Yes Id NN <br /> ll. PROPERTY OWNER INFORMATION <br /> rMALLINGII <br /> WNER NAMI IA£A 84^ N ���� PHONH ^ I •� <br /> STVA <br /> REET ADI)kE5$ V Sle STATE 411 ZW C E o2 <br /> UwNPR TYPE (.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY I DI4 <br /> ISTRICT 6.STATEAGCY <br /> EI7.PARTNERSHIP ❑S.COUNTY AGENCY I]7.PEDERAL AGENCY 411 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNERNAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS ata <br /> CITY ue t STATE Am I ZIFCODF Cl <br /> TANKQWNP.RTVPE LCORM7RA"I"CION 2.INDIVIDUAL •�a.1.fI:AL AGENCY/DISiRIC7 6.STATE AGENCY <w <br /> ❑3.PARTNERSHIP C]S.WU14TY AGRNCY 0 7.FEDRRAI.AGENCY <br /> TV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> T y(TK)1 i( _J.�� � -., - CRIT(916)322-9669 if questions wise - _ •�� <br /> 9V.PETROL.F.UM LIST FINANCIAL.RESPONSIBILITY <br /> INDICATE METIIUD(s) ❑I.SELF-INSURED ❑4,SIIRETY BOND ❑7.STATE FUND ❑10.WCAL GOVT MECHANISM <br /> ❑2.GUARANITE C]S LETTER OF CREDIT ❑R,$TATE FUND&CPO LP.nT.R ❑ 99.OTHER: <br /> 13.INSURANCE _❑6,EXEMPPIUN ❑9,STATE FUND&CD S>z <br /> VL LEGAL.NOTIFICATION AND MAILING ADDRESS <br /> InAc,+,-hieh w16uc ds dd be emd far le¢al nNlfiestinev nodmailmll. <br /> LedW nedfice j_n1xl nteUinp will M acrd to the lank own,enlo. Mx 1 m 2 is checked. 11 1.FACILITY 602 PPR.OPMTY OWNER ❑3.1'ANK OWNER � <br /> VII.APPLICANT SIGNATURE <br /> rere5cam-Im,yt theiefmmmimtInlxidexl hsMn Is nue end au".wnw to dw Inn ofny km.vlCd�. <br /> SIG NA OF APP.ICA DATE r �,) •Tt PHONE ---��- <br /> J a 3 <br /> NAME.OF 1 NT(prim) -^ 4u TMAOFAPPLICANC <br /> 1 U 6Y1 i l <br /> I"A'I'EIJSTFACII.1'fYNUMBER(lork ,--y) •n 199$tJMiRADEC:PR'I'IPICATENUM13ER(P«Inwrw y) ear <br /> UPCF(1/99 c iscd) S Fomlerly SWRCB Fmm A �` <br />