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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT 3. RENEWAL PERMIT 5.CHANGE OF INFORMATION <br />❑ ❑ 7.PERMANENTLY CLOSED SITE <br />rP` <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only i ❑ 8. TANK REMOVED <br />❑ 67EMPORARY SITE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 <br />FACILITY IDk <br />- <br />NEARESt CROSS STREET 401 <br />FACILITY OWNER TYPE 0 4. LOCAL AGENCY/DISTRICT' <br />❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS . GAS STATION El 3. FARM 5. COMMERCIAL <br />TYPE [12. DISTRIBUTOR [14. PROCESSOR [16- OTHER 403 <br />3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />*Ifowner of UST is a public agency: name of supervisor of division, section or office which <br />REMAINING AT SITE �y <br />trustlands? <br />operates the UST (ibis is the contact person for the tank records.) <br />©ME �4(m <br />❑ Yes No 405 <br />406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 401 <br />G Ao <br />PONE 40a <br />© 6'3 6.S <br />z,, <br />MAILING-Ok STREET ADDRESS 409 <br />1701 E cL r e v- fr/� <br />CITY _�, oSTATE <br />S o r l� 7 nJ <br />411 <br />ZIP CODE 412 <br />9 s- 04� <br />PROPERTY OWNER TYPE L CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY! DISTRICT 6. STATE AGINCY <br />3. PARTNERSHIP [35. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />MAILING OR STREET ADDRESS 416 <br />CITY 417 1 <br />STATE 41a <br />ZIP CODE 419 <br />TANK OWNER TYPE ❑ 1. CORPORATION [:12. INDIVIDUAL ❑ 4. LOCAL AGENCY /DISTRICT ❑ 6. STATE AGENCY 420 <br />3. PARTNERSHIP E15. COUNTY AGENCY [17. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) [11. SELF-INSURED [14. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />[:12. GUARANTEE ❑ 5. LEITER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />[13. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. <br />Legal notifications and mailings will be sent to the tank owner unless box I a 2 is checked. ❑ I. FACILITY ❑ 2. PROPERTY OWNER ❑ 3. TANK OWNER 423 <br />VII. APPLICANT SIGNATURE <br />Certification -1 certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF LICAN <br />DATE 424 <br />PHONE 425 <br />J <br />0,q ~2 �-' O G <br />oq� 6/- 338 <br />NAME OF PLICANT (print) 426 <br />TITLE OF APPLICANT 427 <br />�C/<- - <br />!�cies Aktj7, <br />STATE UST FACILITY NUMBER (For local use only) 429 <br />1998 UPGRADE CERTIFICATE NUMB (For locil use only) 429 <br />UPCF (1/99 revised) 8 Formerly SWRCB Form A <br />