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1 <br /> ' TA05i555� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UST Facility <br /> Pepe 1 a 3 <br /> was <br /> 111 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED Srt n <br /> ❑2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> ! I FACILITY I SITE INFORMATION <br /> DBA OR FACILOY NAME 3 FACILITY 10 <br /> Mrs. Betty Foster bbla7a5 <br /> STATE UST FACILITY NUMBER 401 ✓BOX TO INDICATE OWNER TYPE <br /> ❑1 CORPORATION 04 COUNTYA AGENCY- <br /> NEAREST <br /> Hifi <br /> _ qy ❑5 COUNTY AGENCY' <br /> NEAREST CROSS STREET 402 LN 2INDMDUAL <br /> ❑65TATE AGENCY' <br /> ❑3 PARTNERSHIP <br /> P1ndSC0 ❑7FEDERAL AGENCY' 403 <br /> 1998 UPGRADE CERTIFICATE NO. 404 '1Town OUST.,br. 4135 <br /> panty.name o]sv4or al <br /> dNision,section a office eUST <br /> operates tha UST.. <br /> BUSINESS TYPE 0 1 GAS STATION 3 FARM 115 OTHER ❑✓IF InEun ResemBon a trust lams TOTAL NUMBER OF TANKS AT SDE 408 <br /> 406 <br /> 0 DISTRIBUTOR D PROCESSOR 407 1 <br /> IL PROPERTYDWN621NF'ORMATION - <br /> .: <br /> Mrs . Betty Foster <br /> MAILINGORSTREETADDRESS 410 PROPERTYOWNERTYFE VBOXTOINDICATE 411 <br /> 9254 Tamara Jean Rd. 0 CORPORATION ❑3PARTNERSHIP <br /> l(12 INDIVIDUAL ❑4 LOCAL AGENCY DISTRICT <br /> CITY NAME 412 1 STATE 413 ZIP 414 PHONE0 415 <br /> Orangevale CA 955,662 916-988-1240 <br /> - 111 TANK OVAWCRINFORf.AT30N <br /> --- <br /> 416 PHONE 417 <br /> Mrs . Betty Foster <br /> ADDRESS - 418 TANKOWNERTYPE ✓BOX TO INDICATE <br /> ❑6LOCAL AGENCY!DISTRICT 419 <br /> 9254 Tamara Jean Rd. 0 CORPORATION ❑5 COUNTY AGENCY <br /> X12INDIVIDUAL <br /> ❑6 STATE AGENCY <br /> 17 3 PARTNERSHIP <br /> ❑ ]EEO=P.AL AG-M1:,Y <br /> Cary — _.._. 420 STATE 421 ZIP 422 <br /> Orangevale CA 95662 <br /> IV BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY CW HQ4 4 - Call(916)322-9669 if questions arise 423 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> ✓BOX TO [ 1 SELF-INSURED ❑4 SURETY BOND ❑]STATE FUND ❑10 LOCAL GOVT MECHANISM <br /> INDICATE <br /> ❑ 2 GUARANTEE ❑ 5 LETTER OF CREDO ❑ 8 STATE FUND A CFO LETTER ❑99 OTHER: _ <br /> ❑3INSURANCE ❑ 6 EXEMPTION 119 STATE FUND a CD 424 <br /> Vi.LEGAL NOTIFICATION AND MAILING ADDRESS ' <br /> LNy rcTAc9l�naW mul.V wtl be.xM1bttn bnk wrw unlw Coelu2eaeP CNtJtd»Emb <br /> aF�� <br /> iWrsle M�eatreas YwlO be uaeE M Ie0e1 rwlAr�tius W meilep Ad t FACILITY ❑ 2 PROPERTY OWNER ❑ 3 TANK OWNER 425 <br /> W.APPLICANT'SIGNATURE <br /> I vnay ftut v„:MmnMion pvids0lwsn b Vv.a e to tlro Wel d my <br /> APPLICANTS NAME PRINTED AND S 426 APPLICANT'S TIRE 427 DATE 42B <br /> Keith A. Ta La / I �� Agent - 11 /27/00 <br /> (Fmm erly SINRC6 Fv AI • 139 <br />