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UNIFIED PROGRAM CONSOLIDATED FORM q y <br /> TANKS i ,y <br /> UNDERGROUND STORAGE TANKS - FACILITY l <br /> (One page per site) Page_L of� I y1171 <br /> Q <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT [15.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SI 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) 8.TANK REMOVED /�j� 1 f/ <br /> [:16.TEMPORARY SITE CLOSURE 0 7 <br /> I. FACILITY/SITE INFORMATION N� <br /> BUSINESS NAME(S. FACILITY NAME or DBA-Doing Bu,in*s:An 3. FACILITY <br /> IS ass ro �} IDI 64 5 <br /> NEAREST CROSS STREE ol. FACILTTY OWNE TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> Un. ¢tSl,4, lV ,5 N 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS I. AS STATION 3.FARM E]S.COMMERCLAIL 403, ❑2.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 /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> OM2-- ❑Yes C4No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 497, PHONE 408. <br /> TA 6J o Rol9.rn Zaq 273- ZO ZO <br /> MAILING OR STET ADDRESS r 40 <br /> CITY J 410 STATE v 4°. ZIPCODE 41z <br /> $' �sl- 9 s 2 to <br /> PROPERTY OWNER TYPE NJ 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT U6.STATEAGENCY 413. <br /> ❑3,PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. P ONE 415. <br /> Tr\loJ meq) �3S z020 <br /> MAILING OR STREET ADDRESS - r' / 416. <br /> CITY / ,_O� 417, STATE ate. ZIP CODE_ -S 419 <br /> TANK OWNER TYPE �6 I.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago. <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 [14.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LEITER OF CREDIT ❑S.STATE FUND&CFO LEITER [319.OTHER: A)&iAR, <br /> ❑3,INSURANCE ❑6.EXEMPTION [19.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 mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY J@ 2. PROPERTY OWNER ❑3.TANK OWNER 123 <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is we and accurate to the best of my knowledge. <br /> SI NATURE O P CANT DATE 424. PHONE 4u. <br /> 1 <br /> 209) SYS- �3/U <br /> N4ME OF A p IP IT(print) 426 TTTLE OF APPLIC an. <br /> STATE UST FACILITY l'IMBER(Agency we only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Aga,ey useonly) 429 <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.unidoo.org Rev.02/16/00 <br />