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f ' <br /> UNIFIED PROGRAM CONSOLIDATED FORM n n 051�� <br /> rK fJ TANKS <br /> UST Facility <br /> Pape _1 a 3_ <br /> mim ❑1 NEW PERMIT ❑3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION XNPERKANENTLY CLOSED.t <br /> ❑2INTERIM PERMIT ❑A AMENDED PERMIT ❑ 6TEMPORARY SITE CLOSURE <br /> I.FACILITY!SITE INFORMATION <br /> OBA OR FACILITY NAME JFACILITY ID `3_5_� <br /> n ^ 1.. <br /> Mrs. Betty Foster aDla7aS <br /> STATE UST FACILITY NUMBER 401 ✓BOX TO INDICATE OWNER TYPE <br /> ❑4LOCAL AGENCY IC <br /> 01 CORPORATION 05COUNTYAGENCY' <br /> NEAREST CROSS STREET <br /> 402 M2INDIVIDUAL 06STATEAGENCY' <br /> Pinasco <br /> 0 PARTNERSHIP 0 T FEDERAL AGENCY' 403 <br /> 1996 UPGRADE CERTIFICATE NO. 404 M ovm d UST a pU 405 <br /> W ,Y..nvne of setpery sor W <br /> 0,,Wo sec woffXa whet <br /> oP".B UST' <br /> BUSINESS TYPE0 1 Gly STATION E2 3 FARM 0 5 OTHER ❑✓IF 1W Rese..w trVrst_m. TOTAL NUMBER OF TANKS AT Sf1F 406 <br /> 406 <br /> ❑2DISTRIBl1TOR ❑4PROCESSOR 407 1 <br /> j 11 PROPERTY DWNER INFORMATION - <br /> PROPERTY DAHER NAME 409 D <br /> Mrs . Betty Foster C) <br /> MAILINGORSTREETADDRESS 410 PROPERTY OWNER TYPE ✓BOX TO INDICATE 411 _ <br /> 9254 Tamara Jean RC1. 01 CORPORATION 03 PARTNERSHIP <br /> )02 INDIVIDUAL 114LOCALAGENCYIDISTRICT <br /> CITY NAME 412 STATE 413 ZIP 414 PHONE# 415 <br /> Orangevale CA 95662 916-988-1240 <br /> lil TANK OV NERINFORMATSON <br /> NAME 416 PHONE 417 <br /> Mrs . Betty Foster <br /> ADDRESS 410 TANKOWNER TYPE ✓BOX TO INDICATE 04 LOCAL AGENCY I DISTRICT 419 <br /> 9254 Tamara Jean RC1. V0I CORPORATION 05COUNTY AGENCY <br /> —" 2INOMOUAL ❑6 STAT_AGENCI <br /> _ ._ — ❑3 PARTNERSHIP7 FEDERAL <br /> AM STAT_ ^.1 VP 42: <br /> 1 <br /> Orangevale CA 95662 <br /> IV_BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO 4 4 Call(916)322-9669 rf queslions arise An <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY - <br /> ✓BOX TO EX 1 SEL INSURED ❑4 SURETY BOND ❑1 STATE FUND 0 10 LOCAL GOVT MECHANISM <br /> INDICATE <br /> ❑ 2 GUARANTEE ❑ 5 LETTER OF CREDIT ❑ 6 STATE FUND 6 CFO LETTER 0 99 OTTIER. _ <br /> 421 <br /> 1-013 INSURANCE C16 EXEMPTION 0 9 STATE FUND&CO <br /> VI.LEGAL NOTIFICATION AND WRING ADDRESS <br /> 1. YI rclAcatv�W mein will De aen(b Vvf tvY o.+./ur�nu Car 1 w 3 e IbC4eC CNTk me[m b ��ii�� 1 <br /> aaysyy etiplC pe ueG for b9N rro4T<+liau W mel4p M1d 1 FACILITY 2 PROPE(ZTl'OV^MER ❑ 3 ti D..=Ei 425 <br /> VIL APPLICANTSIGNATURE <br /> I<aMy V+et Pe Humelm PA+15^4 Narail a M 6 e to iM Beat W my <br /> :MPLICANTSNAME PRIMED AND SIG 426 APPLICANTS TIRE A27 DATE X25 <br /> Keith A. Ta is Agent 11 /27/00 <br /> (FIM.dl SWRCB Form A) 139 <br />