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Zo �L D. <br /> z�3 - <br /> UNIFIED PROGRAM CONSOLIDATED FORM L <br /> OI TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY Vd•c)46,0'1 <br /> (one page per site) Pageof� <br /> TYPE OF ACTION 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITRAME or DBA-Doing Business As) 3 FACILITYID# <br /> 1 <br /> NEAREST CROSS STREET 401 FA,ILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- <br /> LX-1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESSLaLI.GAS STATION El3.FARM El S. COMMERCIAL ❑ 2.INDIVIDUAL ❑6,STATE AGENCY' <br /> TYPE 2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands7 operates the UST(This is the contact person for the rank records.) <br /> aoq ❑ Yes KNO 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> 315 <br /> PROPERTY, ERNAME 4m PHONE 408 <br /> 707 <br /> MAILING OR STPTET ADDRESS 409 <br /> Cl 410 STA 411 ZIP CODE 412 <br /> TY <br /> l• <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑&STATE AGENCY <br /> [:13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 41q PHONE 415 <br /> u <br /> MAILING OR ST ET DDRESS 416 <br /> CITY 417 STATM 418 ZIP COD J l 419 <br /> TANK OWNER TYPE I.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 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 [110.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. .as{/ <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. [11.FACILITY ❑2. PROPERTY OWNER 1�I 3.TANK OWNER 4D <br /> VII.APPLICANT SIGNATURE ��` <br /> Certificatio the information provided herein is true and accurate to the best of my knowledge. <br /> SIG TORE O DATE 424PHONE 425 <br /> 6-vim -7 D7 s--1 G66 <br /> NA A P T(print) 426 TITLE QF APPLICAD- 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />