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UN-IED PROGRAM CONSOLIDATED FOR11_ TANKS _ T"ERGROUND STORAGE TANKS - FACILITY ' (One page per site) Page_of TYPE OF ACTION / I.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE +00 (Check one item only) ,,Q ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION D 5o7�e �ij` -17T I I I I J. BUS IN ESS NAME(Same as FA ILITY NAME or DBA-Doing Business As 3. FACILITY 1r z- M NEAREST CROSS STREET 4oi. FACILITY OWNER TYPE 0 4.LOCAL AGENCY/DISTRICT' +02 /< J V ❑ 1.CORPORATION ❑5.COUNTY AGENCY• BUSINESS Lj I.GAS STATION 3.FARM COMMERCIAL 103. ;9-1 INDIVIDUAL ❑6.STATE AGENCY' TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER [13.PARTNERSHIP ❑7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. •If owner of UST is a public agency: name of supervisor of division.section or 406. REMAININ AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank rtcords.) / ❑Yes ZLNO II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 4°7. PHONE 401. (//,1/o MAILING OR STREET ADDRESS 409. -3.3 � 5 . CITY410. STATE 411. ZIP CODE 4112. S�aza� PROPERTY OWNER TYPE 0 1.CORPORATION INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT LJ 6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME 414. 1 PHONE 415, zq MAILING OR STREET ADDRESS 416 .3 3 �/L Svc CITY417. STATE�� 411. ZIP CODE i 4119. S�JG��'� Crr r TANK OWNER TYPE Lj I.CORPORATION 4F3T INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 420. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECKtvISM 422 ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is ebecked. ❑ 1.FACILITY ❑2. PROPERTY OWNER3.TANK OW JER +21 VII.APPLICANT SIGNATURE Certification: 1 certify that the information prod e in is tru and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424. PHON / 425. NAME OF APPLICANT(prim 426. TITLE OF APPLICANT 427. STATE UST FACILITY NUMBER(Agency we only) 421. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429 (See Data Element 1,above. UPCF Hwfwre-a(1/99)-1/2 h"p-//n-n-w.unidocs.org Rev.02/16/00