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q1z o� . <br /> UNIFIED PROGRAM CONSOLIDATED FORM f/3l� <br /> TANKS / <br /> ; 7 <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> �r (One page per site) Page_of <br /> TYPE OF ACTION 01 NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400• <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> -,-/7 I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACII nY NAME or DBA-Doing Business M) 3, FACILITY <br /> ,3Prel�l./rl G,r� ID#I,Yj, t. <br /> NEAREs'r CROSS STREET p /?'? •401. FACILITY OWNER TYPE 44.LOCAL AGENCY/DISTRICT* 402. <br /> J91-DaA+40-A V //Q'/l�i �S qi/& OQ-f CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ETL GAS STATION Ll 3.FARM 5.COMMERCIAL 403• ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR [14.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404• Is facility on Indian Reservation 405- •If owner of UST is a public agency:name of supervisor of division,section or sob. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes.-Eno <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> /YI o//-n-C4 sit S r,� ><'� 20.9 95-1 - /7-fr <br /> MAILING OR STREET ADDRESS <br /> 409. <br /> 713 /J/ o,0 tw mom" IV- <br /> CITY >bG�/41;.� a1o. STATE atL ZII'CODE q S ya� alz. <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> /YIU/ <br /> MAILING OR STREET ADDRESS 4T6-- <br /> 7-rT Y <br /> i6CITY 417- STATE 418. ZIP CODE _ 419. <br /> -TTN K OWNER TYPE 1r CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 6 el Call 916 322-9669 ifquestions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED [14.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑S.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> /ki'll.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <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 sem to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY . PROPERTY OWNER [13.TANK OWNER 423• <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE aza. pHO azs. <br /> a2&)-037. 2M- <br /> NAME OF APPLICANT(print) 426• TITLE OF APPLICANT 4z-�• <br /> • 9 p l AIA46�6 1G44*4/G //J <br /> FsT. <br /> ATE UST FACILITY NUMBER(Agency useonly) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agencyaseonly) 429• <br /> e Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />