Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> Jone Da site <br /> Page — of — <br /> TYPE OF ACTION I.NEW SITE PERMIT 0 3.RENEWAL PERMIT 0 S.CHANCE OF INFORMATION(Specs*change- ERMMEMLY CLOSED SITE <br /> (Check oft stens <br /> C34.AMENDED PERMIT local use onw--- VS.TANK REMOVED 400 <br /> TEMPORARY SITE CLOSURE <br /> .. .... ..f <br /> BUSINESS NAME(Same as FACP-ffY NAME or DBA-Doing Business As) 3 <br /> �7M <br /> i Looy), <br /> Os <br /> I <br /> EST S7Ar ,, 401 FAC30Y OWNER TYPE 11 4. LOCAL AGENCYI0ISTRICT- <br /> W'1.CORPORATION <br /> 0 2. INDIVIDUAL 0 S. COUNTY AGENCY' <br /> I BUSINESS 11 1.GAS STATION 0 1 FARM [VS COMMERCIAL ❑ 06. STATE AGENCY' <br /> TYPE 3.PARTNERSHIP <br /> 0 2.DISTRIBUTOR 0 4.PROCESSOR 0 6.OTHER 403 11 t FEDERAL AGENCY- 402 <br /> TOTAL NUMBER OF TANKS IsfadkyonIndian Reservation or owner of LIST is a pttk*Wm:y,.name of superilisor of <br /> REMAINING AT SITE vasdaxxts-; divisim section or offica which operates the UST. <br /> (This is thA contact pawn for ft taink records.) <br /> i 404 0 Yes 405 <br /> 406 <br /> 1t PROPERTY VMER IMFORMATtON <br /> PROPERTY OWNER NAME 407 1 WON <br /> Z1 jii�j <br /> t.=u G-Cy V)6 1 e3 +S'a'31 <br /> MAIL0 OR STREET 409 <br /> f -70 <br /> Cn410T - 411 ZIP COO --)10 412 <br /> Sri[\ <br /> PROPERTY OWNER TYPE <br /> 112, INDIVIDUAL C1 4.LOCAL AGENCY/DISTRrICTj 0 6. STATIE9 AGENCY 413 <br /> V, CORPORATION <br /> C1 1 PARTNERSHIP 115. COUNTY AGENCY 0 7. FEDERAL AGENCY <br /> HIJANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> jj <br /> TANK OWNER TYPE V/, CORPORATION C1 2 INDIVIDUAL 0 4. LOCAL AGENCY I DISTRICT 06. STATE AGENCY 420 <br /> 0 3. PARTNERSHIP 0 S.COUNTYAGENCY 0 7, FEDERAL AGENCY <br /> SOARD OFEQUAUZ1C7iONOST0 <br /> .ST RAGE FEE ACCOV"UMBER"' <br /> TY(TK)HO 4 4 - I I <br /> � j Cail(916)322-9669 if questions arise 421 <br /> ........... <br /> B <br /> E M FINANCIAL RESRO <br /> V,.`.--PTROLEU UST <br /> 7 INDICATE MMOO(S) 0 1. sr-LF4NsuRr:D 04. SURETY BOND 0 7.STATE FUND 0 10. LOCAL GOVT MECHANISM <br /> Cy] GUARANTEE 11 5- LETTER OF CREDIT 0 8.STATE FUND&CFO LETTER 0 99-OTHER. 422 <br /> &r3 INSURANCE 06. EXEMPTION 0 9.STATE FUND&CC) <br /> I -w-f <br /> VI <br /> LE <br /> GTIF ION' <br /> 6&W A <br /> Chack one box to kidicato which address shoU4 be used for legal notifcations and ma&V ❑- <br /> Legal notifications;and mailings will be sant to the tank owner w"ss box I at 2 is checked. 1.FACILITY 0 2. PROPERTY OWNER 0 3.TMKOWNER 423 <br /> VIf APPLICANT SIGNAT <br /> CWration: I certify that the cdonnation provided herein is true and scia"a to the best o(my bmiledge. <br /> SIGNATURE OF APPLICANT/ i DATE424 PHON <br /> NAME OF APPLICANT(peW) 426 OF AP 427 <br /> Cd) <br /> STATE UST <br /> rY NUMBER(For local vse onW 428 1998 UPGRADE CERTIFICATE NUMBER(For local use or,)r) 429 <br /> UPCF(1199 revised) 5 Formerly SWRCB Form A <br />