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r <br /> 0 (ni Is�oz <br /> ITNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page-L of J- <br /> TYPE OF ACTION ❑ 1.NEW SrrE PERMIT ❑3.RENEWAL PERMIT X 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMO VED <br /> ❑&TEMPORARY SITE CLOSURE 44s) <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sameas FACIL17INNA or DDA-Dorn,Business As) 3 FA ILITY # <br /> FA f <br /> 5 <br /> NEAREST CROSS STREET 44Z \ 401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• <br /> yeS m £ AQv JStI <br /> ❑ 1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS X 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ,W 2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 4a3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY- 4u2 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the comact parson for the tank records.) <br /> I404 ❑ Yes>'No 405 /V 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME am PHONE 4cs <br /> PhiL Ft IE2fl9 - 239- 93y <br /> MAILING OR STREET ADDRESS - 4W <br /> $ EA vera <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> M 09 Ai T Gfi C119- 9533 <br /> PROPERTY OWNER TYPE U L CORPORATION .INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TAN OWNER NAME _ 414 PHONE 435 <br /> s�a�h ��5 003 <br /> MAILING OR STREET ADDRESS S 416 <br /> a.o w _ o IFikiTE 'ftk� VAANT5: QA CAA-U� <br /> CITY 4n STATE 418 ZIP CODE 419 <br /> e >A e ` tam r 3 3 c <br /> TANK OWNER TYPE 1.CORPORATION. PC2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 4M <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 C) 17, 1 L4 17 1 01 1 Call 916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> [:12.GUARANTEE ❑5.LETTER OF CREDIT JR 8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box in indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the mink owner unless box I or 2 is checked. ❑ L FACILITY 2. PROPERTY OWNER ❑3.TANK OWNER 40 <br /> VII.APPLICANT SIGNATURE <br /> C ' cation-I cervi y in on pmvi d herein is man and accua¢to the best of my knowledge. <br /> IGNATURE OF APP DATE 1 t i V Z 024 -PHONE 425 <br /> Zoe Z3S y; y <br /> N PLIC T b<tj 426 TITLE OF APPLI NT 421 <br /> 1 C L!P Wti CZ C-�/1 rj./ � _ i41 fi}rt/A Q F Ak ' <br /> STATE UST FACILITY NUMBER(Fpr loeal use only) a38 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 629 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Foran A <br />