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• - o <br /> 10� \� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per sit Pag of_ <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑3.RENEWAL PERMIT [15.CHANGE OF INFORMATION <br /> (Check one Item only) ❑4.AMENDED PERMIT (Specify change) PERMANENTLY CLOSED SITE <br /> ❑6.TEMPORARY SU'E CLOSURE - TANK REMOVED <br /> I. FACILITY/SITE INFORMATION ��V�V/// <br /> BUSINESS NAMEtsameaa FAcnd N ,elEmDBA-Do1,�g a¢'ss nal y FACILITY <br /> J SDu ) Sh ID# <br /> NEAREST CROSS STREET Ili 401. FACII.ITY OWNER TYYIZ <br /> ❑4.LOCAL AGENCY/DISTRICT, 402. <br /> X1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DLSTRBUTOR ❑4.PROCESSOR 6.OTHER ❑3.PARTNERSHIPAGENCY- <br /> TOTAL <br /> NUMBER OF TANKS 404. ➢ ❑7.FEDERAL <br /> Is facie[ ou Indian Reservation JOS. -If owner of UST is a public agency:name of supervisor of division, section or 406, <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank meet&.) <br /> Pj ❑Yes WN. <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTO O NER NAME 407. PHONE <br /> MAILING OR ST ETAgD�RESS , <br /> CTTY� C alo. STAT 411. ZIP CODE I t' <br /> C9 n412. <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKO NERNAME -- a4. PHONE <br /> �S 1al., LC:- end 415. <br /> MAH,ING OR STREET ADD]2ESS �v��c Spit �� 416. <br /> CITY S-fiv G 4D. I STA E <br /> l/Sn _ <br /> � 41x. ZIP CODE 419 <br /> TANK OWNER TYPE L CORPORATION 2,INDIVIDUAL 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY <br /> J2a. <br /> 3.PARTNERSDIP 5.COUNTY AGENCY 7.PFDERAL.AGENCY <br /> TY("fK)I Ig 44- <br /> 1V.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Call(916)3'%9669 if uestions arise <br /> J:1. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDIC.ATG METHOD(s) ❑1.SELF-INSURED ❑ LRETY BOND ❑7.STATE FUND ❑ LOCAL GOVT <br /> ❑:.GUARANTEE �ETTER OF CREDIT ❑8.STATE FUND&CFO LETTER 1319910. MECHANISM.OTHER: 433' <br /> ❑3. <br /> INSURANCE ❑5.EXEMPTION <br /> [19.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Legal <br /> Legane box to irulicala which xddr¢ss should be used 1'or legal nolifcalimha and mail ng. <br /> Legal nollficatiota:md mailings will be smtt 10 the tank owner unless box I or 2 Is checked rI.FACILITY 2. PROPERTY OWNER <br /> fp� [:13.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Cenificalion: I certify that the information provided herain is true¢od accwate 10 tlhe best ofmy kwwledge. <br /> SIGNAT APPLICA T DATE az4. PHO�JNE 421. <br /> NAME OF A pLICANT - 4 �7 /L <br /> (print) 'y�,, 436. TTTLE OF APPLIC NT 427 <br /> C,,.ti. � Gl & &I - OEC D <br /> STATEUST FACB,ITY NUMBER IA,,,ey¢a<omy) a2s. 1998 UPGRADE CERTIFICATE NUMBER <br /> (See Data Element 1,above. (Agn,cy erne omy) 4zs. <br /> UPCF Hwfwrc-a(1/99)-1/2 littp:/twim.anldoes.org <br /> Rev.02/16/00 <br />