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7!19(2092 19:96 464013E ENVIRONMENTAL PAGE 03 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (ane page per siml <br /> Pisa _ el _ <br /> TYPE OF ACTION r I NEw SRE PERMIT r 3.RENTAIAL PERMIT 1X5.CHANGE OF INFORMATION(5Ae Y Vw - r T PERMANENTLY CLOSED SITE <br /> (CA9Ff aAA.Iem wryJ [_A AMENDED PERMIT I,F,(A:[eAln Name Change r 6.TANKREMOVED Apo <br /> r 6.TEMPORARY SDE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> 5U51NES5 NAME(Sam9v:FACILITY NAME w DBA-a."euW191a A.1 ] FACILITY IDA F 0 0 �, 4 5 5 <br /> WLM, Inc. <br /> NEAREST CR06u'STREET fat sACWTY OWMER TYPE k LOCAL ACENCY1016TRICT' <br /> Morata XXI. CORPORATION r S. COUNTY AGENCY' <br /> BUSINESS TYPE XyA.GAS STATION r 3.FARM r S.COMMERCW. r Z. INDIVIDUAL [ 6 STATEAGENCY' <br /> r Z.DISTRIBUTOR r f.PROCESSOR r 6.OTHER r 1 PARTNERSHIP r !. FEDERAL AGENCY' ADZ' <br /> -C3 <br /> TOTAL NVM 0.OF TANK$ IN(AL411a T hMLM RNamAP:x.At EI.f �M-.a er� ��.,'I+,USTm d <br /> REMA1Nw0 AT SITE ITMif if e1Ac Tn PwaaP Iw IM W9NMAw.I <br /> Ap, 3 rY9a Na ,cs f06 <br /> 11,PROPERTY OWNER INFORMATION <br /> PHONE foe <br /> PROPERTY OWMERNAME AV, 415-447-6899 <br /> Robert R. Wall <br /> MAAINGOR STREET ADORE53 f09 <br /> 2001 Union Street, Ste. 300 STA n, nP coot .+a <br /> .10 CA 94123 <br /> San Francisoc <br /> PROPERTY OWNER TYPE wr 2 INDIVIDUAL r 4. LOCAL AGENCY I OISTRICT r S, STATEAOENCY 113 <br /> pix. CORPORATION 6 CWNTYAGENCY r 7, FEOERALACENCY <br /> r J PARTNERSHIP r <br /> 111.TANK OWNER INFORMATION <br /> PHONE .15 <br /> TANK OWNERMAME AIA <br /> Robert R. Wall <br /> MAILING OR STREET ADORESS A16 <br /> 2001 Union Street, Ste. 300 STA E 415 DP Cu 419 <br /> CA 94123 <br /> San Francisco <br /> TANK DYMER TYPE Nryy r Z. INOMDUAL r 0. LOCAL AGENCY I DISTRICT r 6. 6TATEAGENCY A]D <br /> 6u>, CORPORATION r T. FEDERAL AGENCY <br /> F ]. PARTNERSHIP r 6. COUMTYACENGY <br /> 17 KI <br /> TY(TKI HQ A 4 - 3 5 4 7 Call(916)372-9669 if questions arise <br /> GOY-T MECNAN19M <br /> INDICATE METHOOIS) r 1. SELFANSURED r A, SURETY BONA r T, STATE FUND r 10. L000I <br /> f�prF�ri GUARANTEE r 5. LETTER OF CREDIT r a. STATE FUND a CFO LETTER r 99. OTHER Au <br /> may_ INSURANCE r fl Exempn0N r B. STATE FUND A CO <br /> ma�yy. PROPERTY OWNER r J TANK OWNER .13 <br /> GfMG am OAa le inygro.l*Cl fddlffa fnPWi Of ufe6lPlayl mlJlFPlbn u+l mlll4q. r I. FACILITY A�`A <br /> a <br /> DI�1AotbP I cants IInA 6M Malmwwn wP.vftl M9m b WA el14 AEtlOAIP a PM O6Y PI mY xrwwM4Ea, fN PHONE f26 <br /> SK�TURE yt.p/LS'+-� <br /> CAM 07/11/02 415-447-6899 <br /> Ve TITL3Gg DFAPPLICANT A=i <br /> NAME OF PUCANT(P,,M AQm1nlS tatOr <br /> B.M. Samson <br /> STATEV5TFACILITYNVMBER(FVA Rf ") fZ6 1991 UPGRADE CEPTGICATE HUMBER(Fp Mc/(VFf w'y'! ` `I <br /> L �ISII U <br /> JUL 15 2002 <br /> E p RM�M SERV CESjH <br />