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r z 6-7 2v- <br /> UNIFIED PROGRAM CONSOLIDATED FORM '),t oo <br /> UNDERGROUND STORAGE TANKS -FCH <br /> �g „n <br /> ( 50 <br /> wperi <br /> of �JC <br /> TYPEOF ACTION ❑ LNEWSTTEPER-MIT ❑3.RENEWAL PERMIT ❑5-CHANGE OF INFORMATION ❑ 7.PERMANENILY l7A5ID SCTE <br /> ((]wck ane it®odY) ❑4.AMENDED PERMIT specify change local use o* &.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAMES.as FAONA ar DBA-Dune Buinm As) 3 FACILITTYYIDY I <br /> e 5 r -c )J <br /> 9 ACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• <br /> NEAREST CROSS STREET 5,COUNTY AGENCY• <br /> ❑ 1.CORPORA770N, ❑ <br /> BUSINESS 1.GAS STATION 3.FARM 5. COMMERCIAL X2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR 6. OTHER M [33.PARTNERSHIP ❑7.FEDERAL AGENCY' 4(t! <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or <If mm UST(Ibis li .conhct person for dank sor esecosds)��an Wofae which <br /> REMAINING AT SITE tntstlands. <br /> nab <br /> W o .A ❑ Ya No 015 <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME IAUZN�x <br /> PHONE��MS Al eMAILING OR STS AD�3 �,tea( s8 ' to STATE CODLE, / n: <br /> CRYe V- Vi llQ q ) tP0CPROPERTY OWNER E I.CORPORATION .INDIVIDUAL 4. TRICT 6.STATEAGENCY3.PARTNERSHIP ❑5. ❑7.FEDERAL AGENCY <»IIL TANK OWNER INFTANK OWNER NAME , ONE as <br /> Mff_ /I) it 2 B a -4 <br /> n16 <br /> MAILING OR STREET ADDRESS <br /> 8 7s <br /> Ez - 413 STAm ZIP CODEu9 <br /> CITY q A 2 Vc2T'4_ yT_ ° A <br /> TOWNER TYPE I.CORPORATION koV,INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 6.STATEAGENC1 am <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44- <br /> Call 916 322-9669 if u@sd0R6 a5i6Sl <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE MEfHOD(s) 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LEITER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ 99.OTHER: nu <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chxk one hoz to indicant which address should be used far legal odi6catioan and mailing. 4a <br /> Legal notifications;and mailings will be sent to the hank owner udess box I or 2 is ckc&cd ❑ L FACILITY ❑2. PROPERTY OWNER C3 3.TANK OWNER <br /> VR.APPLICANT SIGNATURE <br /> Catificatian-Icesulythet Bheinfosmatioo mn&d aministsoc and aaauatemthe bra ofmy knowkdg<. 425 <br /> SIGNATURE OF APPLICANT 4M HONE <br /> DAO I -z S -O 7 <br /> 426 TITLE OF APPLICANT nn <br /> NAME OF APPLICANT(pnn <br /> (Jf- C l J les <br /> '41 <br /> ATE UST <br /> STFACILITY NUMBER(Fu lard us<odr) <br /> 43+ 1998 UPGRADE CERTIFICATE NUMBER(F«loot..*I <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />