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UNIrIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> U"ERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION / I.NEW PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION <br /> (Check one item only) l�� ❑ ❑7•PERM°NEN VE CLOSED 517E goo. <br /> 4.AMENDED PERMIT <br /> (Specify change) [__1 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same a FA ILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> DE <br /> Z"Xl- I I [ :1 H <br /> NEAREST CROSS STREETC sat. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• 402 <br /> G K ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS U 1.GAS STATION U 3.FARM COMMERCIAL 403. 02.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [:16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> 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. <br /> REMAININ AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> / ❑Yes o /_// <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 7_F__ONE <br /> MAILING OR STREET ADDRESS <br /> �� �' S �LSv.J C✓� .09. <br /> CITY 110 STATC� all ZIP CODE ate_ <br /> S�4O__S- <br /> PROPERTY OWNER TYPE 0 1.CORPORATION INDIVIDUAL 4.LOCAL AGENCY/DISTRICT LJ 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME /��`^ f/� � /_�� 414. PHONE�C „ � 415 <br /> MAILING OR STREET ADDRESS 'V GG/7 416. <br /> CITY 4 ,77TE 41s, ZIP CODE 419, <br /> 5: O5 <br /> TANK OWNER TYPE Lj I.CORPORATION E31INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECRACNISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ,,E1.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and rnasling. I- <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked ❑ 1.FACILITY ❑2. PROPERTY OWNER,,Oe3.TANK OWNER 421. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that the information provide herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT ZDATE ✓ 424_ PHO N 425. <br /> NAME OF APPL ANT(p nt) - 426_ TITLE F APPLI ANT 427_ <br /> STATE UST FACILITY NUMBER(Agency use only) 425. 1 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://"w.unidocs.org Rev.02/16/00 <br />