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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page_of_ TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT Specify Change local we only Ji,8.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION BUSINESSNAME(go..tF�AC=YNAMEmDBA-D.h4Busin=As) s FACILITY D)ff AiJculFCL �1�2.IYT " NEAREST CROSS STREET 401 AGILITY OWNER TYPE [14.LOCAL AGENCY/DISTRICT* L-em n1 1°e_91 P. ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS El I.GAS STATION ❑3.FARM El 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑�y 6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR El 4.PROCESSOR El 6. OTHER 403 El - 3.PARTNERSHIP %7.FEDERAL AGENCY* 402 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 REMAINING AT SITE y trastlands7 opaatesthe UST(This is the contact person fm the took records.) ! Dl ❑ Yes ❑ No 405 406 IL PROPERTY OWNER INFORMATION PR , OWNERNAME 407 PHON$,['/C `� 4p S C 2n Sl r! C MAILING(45GRS ET ?I�B � enue �`�'�` �'lG�r Ca ,� CITY 410� STATE 411 ZIP E 412 1 a� PROPERTY OWNER TYPE 0 1.CORPORATION Ll 2.INDnMUAL U 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY 197.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 4w PHONE 415 MAILING OR STREET ADDRESS 416 CITY 417 1 STATE 418 1 ZIP CODE 419 TANK OWNER TYPE 0 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY QM [13.PARTNERSHIP ❑5.COUNTY AGENCY ,®7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY HQ 44- 1 1 1 1 1 1 Cal] 916 322-9669 if quesfions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER - ❑ 99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD a2z VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal nati5eafiwa and mailing. r{Y1 Legal notitimtioos and mailings will be seat to the tank owner mien box 1 m 2 is checked. ElL FACILITY X 2. PROPERTY OWNER ❑3.TANK OWNER 421 VII.APPLICANT SIGNATURE C 'm-1 certify that the' formation provided herein is nueand accurate to the but ofmy knowledge. GNC OF P C e DATIi6 O( 4H 2�NE, -07 42s F APPLIC (print) 4W TITLE PLIC /1,/�OL 427 e. � -I � � � roc do r STATE USI FACILITY NUMBER(For toed my only) PGRADE CERTIFICATE NUMBER(I ur low use only) 429 UPCF(1/99 revised) 8 Formerly SWRCB Form A