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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> ,�� Page _ of _ <br /> TYPE OF ACTION l , NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSE SITE <br /> (Check one item only) local user only) r S.TANK REMOVED <br /> F 4.AMENDED PERMIT <br /> r 6.TEMPORARY SITE CLOSURE a <br /> 1.FACILITY I SITE INFORMATION ?� <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY to a <br /> PAQ INc , D6A FW 4 L^s DD oa5� 3 • <br /> NEAR ST CROSS STREET 401 FACAITY OWNER TYPE L 4. LOCAL AGENCY/DISTRICT• 71 <br /> e[�{(M� -Q'{• Iy1. CORPORATION r 5. COUNTY AGENCY` \` VVV <br /> BUSINESS TYPE VI.GAS STATION P 3.FARM r S.COMMERCIAL - r 2. INDIVIDUAL <br /> r 6. STATE AGENCY• <br /> r 2.DISTRIBUTOR r 4.PROCESSOR I'S OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agerKy:name of supervisor of <br /> REMAINING AT SITE trostlands7 division,section or office which operates the UST. <br /> j s (This is Ne contact Person for the tank records.) <br /> '{l 404 r Yes r No 405 '106 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 405 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY. 410 TATE 411 21P CODE 412 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY L7. FEDERALAGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> aPc 4 La 1- 491 <br /> MAILINGO ojT ADDRESS 416 <br /> gots L omev Sa.clrAMenl tQ014 -' SIAL <br /> CITY 417 TAE 418 ZIP CODE 419 <br /> sl; oki e-4o�J CQ 9S= !o <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> Sir CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 - Call(916)322-9669 0 questions arise 421 <br /> I'M <br /> INDICATE METHOD(S) L I. SELF-INSURED r 4. SURETY BOND 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r,�,/2 GUARANTEE r S. LETTER OF CREDIT r 8. STATE FUND d CFO LETTER r 99. OTHER: <br /> Y3. INSURANCE r 6. EXEMPTION r 9. STATE FUNDS CD - 422 <br /> Check one Gov to indicate which address should be used Mbgal wtifl®lions antl mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal notifications and mailings will sent to a tank owner les r is <br /> Cali I Andy that the inf , tion provided herein is two and accurate to the Gest of my knowledge. <br /> 31 TUREO APVLIC DATE zq/O� 424 f�HONE�_h' ^L�_ Q1-7 425 <br /> N OF ICA`NT(pnn 426 TITLE OF APPLICANT 427 II <br /> (Jt� (•�cJ �f <br /> J IM C1Z ISY I R1aEl� <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fix tical use only) 429 <br /> UPCF(1199 revised �' 6 �y � Formerly SWRCB Form A <br /> a f�7a de s u" 4I�0ID i <br />