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�R 05(- 't .e <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TAN <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> one a _ site <br /> Pape _ a1 _ <br /> TYPE OF ACTION Cl 1 NEW SITE PERMR D 3.RENEWAL PERMfT ❑ 5.CHANGE OF INFORMATION(SPeGfy Eh8Me- ❑ PERMANENTLYCLOSEO SRE <br /> fOhsn aem ClAM <br /> wvyl ,1 1 <br /> 4. ENDEO PERMR /oca�trse oNy) 5 TANK REMOVED G'A <br /> 1'D 6.TEMPORARY SRE CLOSURE <br /> j I.FACILITY I SITE INFORMATION <br /> IESS NPNE ISame as FACILD'Y HANE or DBA-D NBuliness As) 3 FACILITY <br /> NEAREST CROSS STREET t Ot FACILfiY OVMER TYPE D 4 LOCAL-AGENCY/DISTRICT' <br /> 1. CORPORATION D 5. COUNTY AGENCY' j <br /> BUSWESS , INOMDUAL D 6. STATEAGENCY' <br /> TYPE ❑ 1.GAS STATION ClD 3.FARM 5.COMMERCIAL D 3 PARTNERSHIP <br /> D 2.DISTRIBUTOR D A.PROCESSOR D 6 OTHER 40.7 I ❑ 7. FEDERAL AGENCY' 40'2 <br /> TOTAL NUMBER OF TANKS Iz maldy on I mi Resanaloon or 'If Ownat of UST u a pudic a9 ,name of suc iscr W <br /> REMNNING AT SITE Wz11aP45? cWsbn.se or office nfiirlr operates Ote UST. <br /> (This is Ore contact .on for Bic farit recortls.) <br /> WA404 ❑Yes LT No d05 <br /> IL PROPERTY OWNER.INFORMATION //�ss �] Q. <br /> P RTY ONMER NAME 407 1 ONE /7 I'2)�.,I <br /> a <br /> CR Hca AOOORESS 409 <br /> / STATE 411 ZIP COUE�groc�3 412 <br /> I _ <br /> PROPERTY ONMER TYPED 2. INOMDUAL ❑ 4. LOCAL AGENCY/DISTRICT D 6. STATE AGENCY 413 <br /> T CORPORATION D 3 PARTNERSHIP ❑ 5. COUNTY AGENCY 07. FEDERAL AGENCY <br /> I Ill.TANK OWNER INFORMATION <br /> DMER I E 414 PHONE 415 <br /> C Eds h <br /> OR R ET ADO SS 411 <br /> I ' <br /> 411 STATE 415 ZIP COOE 419 <br /> �1�J,JA1` <br /> TANK OMMER TYPE ❑ 2. INOMDUAL D 4. LOCALAGENCYIDISTRICT 06. STATE AGENCY 420 <br /> 1. CORPORATION ❑ 3 PARTNERSHIP D 5. COUNTY AGENCY D T. FEDERALAGENCY <br /> j - IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 4 4 '�Call(916)322-9669 if questions arise 421 <br /> V.-PETROLEUMUSTFINANCIALRESPONSIBILITY <br /> INDICATE METHOO(SI D 1 SELF-INSURED D 4. SURETY BOND D 7. STATE FUND 010. LOCAL GOVT MECHANISM <br /> D 2 GUARANTEE ❑ 5. LETTER OF CREDIT ❑ B. STATE FUND 6CF0 LETTER Cl 99. OTHER: I <br /> D 3. INSURANCE D 6. EXEMPTION ❑ 9. STATE FUND 6 CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> I <br /> DHEA One Dozro9diola nllirll aoGess SMUNa useO for k9al rotificatgm aM mairg. ❑ 1. FACILDY D 2. PROPERTYOV.NEF Cl 3. TANKCWNER 423 <br /> Legal roMKa4ons aM ma9aps v 11 W sOm b Ne lank P.rer uNess Ooz 1 w 2 is SNeaea. <br /> VII APPLICANT SIGNATURE <br /> Cert! tion I taHay Nat me iCarmatim prwNeO Herab c We aM ecaaala b Or Bes[a my Ysto'ale09e. <br /> ft�llGATE 4N 1 NONE -%426 PLI d2T � <br /> STATE UST FACJU Y NUMBER fFor bEW vse pNy) 428 1996 UPGRADE CERTIFICATE NUMaER(Fo'axaluu ONy) 419 <br /> UPCF(1199 revised) 5 Formerly SWRCS Fenn A <br /> q'- ( T-0 I <br /> gIPI. Ie4s) <br />