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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UST Facility <br /> v.9. 1 n 3 <br /> ana ❑1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION IN T PERMANENTLY CLOSED SITE�a00 <br /> ❑2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6TEMPORARY SITE CLOSURE <br /> -- � <br /> I.FACILITY!SITEINFORMATION <br /> DBA OR FACILITY LANAE 3 FACILITY 10 <br /> Mrs. Betty Foster <br /> -4 <br /> Mrs. 00/9 7A6 <br /> STATE UST FACILITY NUMBER 401 ✓BOX TO INDICATE OWNER TYPE <br /> Cl 4 LOCAL AGENCYIOISTRICT <br /> 111 CORPORATION ❑5 COUNTY AGENCY' <br /> NEAREST CROSS STREET 'O C AD2 gI2 iNOMDUAL ❑6 STATE AGENCY' <br /> V ❑3 PARTNERSHIP 7 FEDERAL AGENCY 403 <br /> Pinasco Q5.�.15 <br /> 1998 UPGRADE CERTIFICATE NO. ADA V anxr oT UST a pIATic 405 <br /> panty.name of supervisor d <br /> Civnion, <br /> operates ST seC�onaU <br /> ft 81e UST.. <br /> BUSINESS TYPE ETI GAS STATION M3FARM ❑50THER ❑✓IF lrqun ReservationawrilarlEs TOTAL NUMBER OF TANKS AT SITE 408 <br /> 406 <br /> ❑2D19TAIBUTOR ❑4PROCFSSOR Nl 1 <br /> 11.PROPERTY OWNER INFORMATION -� <br /> PROPERTY OWNER NAME `' D <br /> Mrs. Betty Foster <br /> MAILING OR STREET ADDRESS 410 PHOPERTYOWNERTYPE ✓BDXTO INDICATE 411 <br /> 9254 Tamara Jean Rd. y❑�1 coRPoR ,noN ❑3PARTNEASHIP <br /> X112 INDIVIDUAL ❑4 LOCALAGENCYIDISRi1CT <br /> CITYNAME 412 STATE 413IIP 414 PHONED 415 <br /> Orangevale CA 95662 916-988-1240 <br /> 3It TJVT1K OW 1ER NFO1 <br /> NAME 416 PHONE 417 <br /> Mrs. Betty Foster <br /> ADDRESS 418 TANK OWNER TYPE VBOX TO INDICATE ❑4 LOCAL AGENCY I DISTRICT 419 <br /> 9254 Tamara Jean Rd. ❑1 CORPORATION ❑5COUNTY AGENCY <br /> ,ZI2INDIVIDUAL 0 6STATEAGENCY <br /> ❑3 PARTNERSHIP <br /> ❑T FEDERAL AGENCY <br /> CRY —_— 420 STATE 421 LP a+ <br /> Orangevale CA 95662 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT.NUMB? <br /> TY lTK)RQ 4 4 _ Call(916)322-9669 if questions arise <br /> V. PETROLEUM UST FWANGIAL RESPONSIBILITY;.. I <br /> .BOX TO EX 1 SELF-INSURED ❑4 SURETY BOND ❑T STATE FUND ❑10 LOCAL GOVT MECHANISM —, <br /> INDICATE <br /> ❑ 2 GUARANTEE ❑ S LETTER OF CREDIT ❑ 8 STATE FUND 8 CFO LETTER ❑99 OTHER: <br /> ❑3INSURANCE ❑ 6 EXEMPTION ❑ 9 STATE FUND d CD 4Ia <br /> VI,LEGAL NOTIFICATION AND MAILING ADDRESS -- <br /> L^Wl rolAoti.�n+M ma�np wieLa wnlbnw mrY.w+w�nbs�bmtla2url�ebs¢ Ct hwr Cmb.. .�ryry - <br /> 'rWvla wTE�adtress4uW Wu»etor bpel elotf4auuu anEmeJvp tLp1FACILf1Y ❑ 2PROPEKTYOWNER ❑ 3LANK OWNER +25 <br /> VII:APPLICANT'SIGNATURE J <br /> 1 oeiMy 1M1W tln reolmatiwl prwidM terain a 4w 8 m m,nest d mY � ____.__ <br /> APPLICANT'S NAME PRIMED AND SIG yE AM APPLICANT'S TIRE 421 DATE -- 428 <br /> Keith A. Talria i� 1 //�� Agent 11 /27/00 <br /> (F,r J,,S CB Form A) 139 1 <br />