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UNIWD PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> o� a paTsra <br /> &{ papa _ of _ <br /> TYPEOFACDON 01.NEWSITE PERMIT 03.RENEWAL PERMIT AIS.CHANGEOFINFORMATION(Spw/yonange- 07.PERMANENTLY CLOSED SITE <br /> (Cheat aro Imm aNy) <br /> 0 4."ENDED PERMIT local use of" ❑ BTANK REMOVED 400 <br /> 0 S.TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY'NIAM oro -Domesuamam As) 3 FACILITYIDa1 <br /> _ <br /> I I I I I i I <br /> NE <br /> ARS CROSS E\a SC}oG 41 FACILITY OWNER TYPE 5'4. LOCAL AGENCWDISTRUT <br /> aw1S <br /> 01. CORPORATION 0 g COUN Y AGENCr <br /> BUSINESS 0 2. INDMDUPL 13 & STATE AGENCY' <br /> TYPE 0 1.GAS STATION 0 1 FARM 0 5.COMMERCIAL ❑ 3. PARTNERSHIP 0 T. FEDERAL AGENCY 402 <br /> 0 2.0ISTRIBUTOR 0 4.PROCESSOR e.OTHER 40.1 <br /> TOTALNUMBEROFTANKS Ie fapYly9 lydam RaeaM.r I 'Ir ownrol USTapubNc eparloY lama al sup4wlera! <br /> REMAINING AT SITE auatlane,7 bis aam.satlpn or oMo wnitlf operate,me UST. <br /> 404 (Title 4 me.=person for g <br /> M.Isnk rei) <br /> D IG <br /> Yea Na 405 � <br /> II.PROPERTY OWNER INFORMATION <br /> P OPE TY OWN RNAME 407 PHONE 408 <br /> e�e o v)Aev. IM <br /> MAIUNG OR STREET RES 409 <br /> 02 R ea. <br /> CITY t 410 1 STATE 411 ?JP=DE 412 <br /> [-ac 9sz.4bz <br /> PROPERTY OWNER TYPE 0 2. INOIVIOUM- ,K4. LOCALAGENCY/DISTRICT ❑ S. STATEAGENCY 413 <br /> ❑ 1. CORPORATION 0 3. PARTNERSHIP ❑ 5. COUNTYAGENCY ❑ 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PF IIE 415 <br /> 'SaMe o <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 1 SATE 41a ZIP CODE 419 <br /> TANK OWNER TYPE 0 L INDIVIDUAL 4. LOCALAGENCY I DISTRICT ❑ S STATE AGENCY 420 <br /> ❑ 1. CORPORATION 0 1 PARTNERSHIP 0 5. COUNTYAGENCY 0 7. ��DERALAGENOY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO 4 1 4 - Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ME HOO(S) 0 1. SEL NSURED 0 4. SURETY BOND 0 7. STATEFUND 10. LOCAL GOVTMECHANISM <br /> 0 2. GUARANTEE 0 5. LEITEROFCREDIT 0 B. STATE FUND&CFO LETTER ❑ 99. OTHER: <br /> 0 3. INSURANCE ❑6. EXEMPTION 0 9. STATE FUND&(= 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Crack one b4r toBade,inaiofa ahCl"oress oa usaa trlpW npmptlru rm mains <br /> Legal nomiabons=mihgaeai M arum me trr oawrtntlav Sox t r21s N1aNfatL ❑ 1. FACILITY 2 PROPERTY OWNER 0 3. TANKOWNER 423- <br /> - -- VB.APPLICANT SIGNATURE - <br /> IaerMY Wt111s MreilNmr rm amwm mm.De,ral pmwMap& <br /> TURE OF GATE 424 1 PHONE 425 <br /> OWv�.ea a 8w �p Z.O OI 6-�J Z-�53S- <br /> ARpu us rrrLE cANr rsT <br /> VIA,l h Nn)v. . SSlS <br /> STATE UST FACILITY NUMBER(F mol ma o.W429 <br /> 7 <br /> ECERTRTCATENUMBER(F Ioolaa..V 429 <br /> UPCF(1199) Famtery SWRCS Form A <br />