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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY ` 3 <br />page site e of <br />(One P per Page P g - <br />TYPE OF ACTION ❑ I. NEW PERMIT ❑ 3. RENEWAL PERMIT 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 />I. FACILITY/SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME., DBA -Doing Business As) 3. <br />LUki T -U N G <br />FACILITY <br />ID# <br />C <br />JA <br />L <br />�+ <br />CI <br />C) <br />�t -2 <br />1 <br />6 <br />{' <br />q�CUN1 <br />1 <br />I. <br />NEAREST CROSS STREETR ` p L PATH 401. <br />`' <br />FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT* 402. <br />❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />[K2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />BUSINESS ❑ I. GAS STATION ❑ 3. FARM [15. COMMERCIAL 403• <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR [26.OTHER <br />TOTAL NUMBER OF TANKS 404• <br />REMAINING AT SITE ( <br />Is facility on Indian Reservation 405. <br />or trust lands? <br />❑ Yes 9110- <br />}K%II <br />' If owner of UST is a public agency: name of supervisor of division, section or 406. <br />office which operates the UST. (This is the contact person for the tank records.) <br />11. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAMEP 407• <br />KEv i W �KMU <br />PHONE 408. <br />(2-Oq')�h'13-4SC�� <br />MAILING OR STREET ADDRESS 409. <br />b�i'7 6 til Ei� T irq tom" E <br />CITY I 410• <br />GK'j c N <br />STATE 41 L. <br />C,�. <br />ZIP CODE 412. <br />�i5zIC� <br />PROPERTY OWNER TYPE 1. CORPORATION Mr24. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 413. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME - 414. <br />PHONE 415. <br />MAILING OR STREET ADDRESS 416. <br />CITY an. <br />STATE 418. <br />ZIP CODE 419. <br />TANK OWNER TYPE ❑ 1. CORPORATION ❑ 2. INDIVIDUAL [14. LOCAL AGENCY/DISTRICT [16. STATE AGENCY 420. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION t)ST STORAGE -FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br />V. PETROLEUM"UST.FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ❑ 1. SELF-INSURED [14. SURETY BOND @;/. STATE FUND ❑ 10. LOCAL GOVT MECHANISM 422 <br />❑ 22 .GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />[$'3 INSURANCE [16. 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 trailing. <br />Legal notifications and mailings will be sent to the tank owner unless box l or 2 is checked. ❑ 1. FACILITY [12. PROPERTY OWNER ❑ 3. 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 <br />DATE 424• <br />PHO 425. <br />NAME OF APPLICANT (print) 426. <br />PAUL A. P1 �P)K <br />TITLE OF APPLICANT427. <br />�'iZGJ. N1�� <br />STATE UST FACILITY NUMBER (Agency use only) 428. <br />(Sce Data Element 1, above. <br />1998 UPGRADE CERTIFICATE NUMBER (Agency use only) 429. <br />UPCF Hwfwrc-a (1/99) - 1/2 http://www.unidocs.org Rev. 02/16/00 <br />