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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />MAILING OR STREET [)[) _j�� F <br />(A -7n Lam <br />— <br />- <br />Page — of — <br />TYPE OF ACTION 0 1. NEW SITE PERmrT 0 3. RENEWAL PERMIT 0 s. CHANGE OF INFORMATION rAcedly dungo - <br />(Check one dem ciriiiy) <br />0 ERMIANENTLY CLOSED SITE <br />V8. <br />410 0 STCJA 411 <br />cum <br />0 4. AMENDED PERmrr kal *nW_, <br />TANK REMOVED 400 <br />PROPERTY OWNER TYPE <br />CORPORATION <br />0 c TEMPORARY SITE CLOSURE <br />116, STATE AGENCY <br />0 T. FEDERAL AGENCY <br />413 <br />C.-FACIL'ay :INV T, <br />IsfrE ON <br />.. .... . ..... <br />. .... <br />z, <br />X <br />BUSINESS NAME (Same as FACILITY NAME of DBA - Doing Business Asl 3 <br />v b�. <br />f�W� !D <br />. .... .... . <br />....... . .. . ......... <br />. ... ...... <br />......... ..... . ... . .. .. .... . .... <br />. ....... .... . .. ...... <br />415 <br />— <br />TMJ <br />. ... ....... <br />........ . . <br />n. <br />� EST <br />E�� S r <br />401 <br />tACVrY OWNER TYPE <br />11 4. LOCAL AGENCY/DISTRICT' <br />'11W IE*TA�� <br />[Irl. CORPORATION <br />I INDIVIDUAL <br />3. PARTNERSHIP <br />0 S. COUNTYAGENCY- <br />0 6. STATEAGENC-1- <br />I BUSINESS 11 1. GAS STATION 0 3. FARM COMMERCIAL <br />TYPE ERCIAL <br />0 2 DISTRIBUTOR <br />0 4. PROCESSOR 11 6. OTHER 403 <br />Certification: I certify that the Womation Provided herein is true and somrate to v* best d my hw~ge. <br />07, FEDERAL AGENCY- 4C2 <br />TOTAL NUMBER OF TANKS <br />REMAINING AT SITE <br />Is facility on Indian Reservation or '11 owner of LIST is a public agency name of supervisor of <br />triAdands, diiiisiion, section or cifte which operates this LIST <br />YPHO <br />404 <br />(This is the contact person for fie tark r000rds.) <br />Yes 34" 405 <br />406 <br />.�:ii. .-PROPER ry..OWNER:INFP ON <br />PROPERTY OWNER NAME <br />40 <br />MAILING OR STREET [)[) _j�� F <br />(A -7n Lam <br />— <br />- <br />I <br />401 <br />CFT <br />410 0 STCJA 411 <br />ZIP COD <br />412 II <br />PROPERTY OWNER TYPE <br />CORPORATION <br />0 2. jNomouAL 0 4. LOCAL AGENCY/ DISTRICT <br />0 3. PARTNERSHIP 11 S. COUNTY AGENCY <br />116, STATE AGENCY <br />0 T. FEDERAL AGENCY <br />413 <br />IIIT TANK OWNER INFORMATION <br />z, <br />TANK OWNER NAME <br />9a,fne 0S G <br />414 <br />I <br />PHONE <br />415 <br />— <br />MAILING OR STREET ADDRESS <br />416 <br />UPCF (11`99 revised) 5 Formerly SWRC13 Form A <br />CITY 417 STATE 418 <br />ZIP CODE <br />419 <br />TANK OWNER TYPE <br />C1 2. INDIVIDUAL 11 4. LOCAL AGENCY[ DISTRICT <br />06. STATE AGENCY <br />V/1CORPORATION <br />0 3. PARTNERSHIP 0 s. couNTYAGENcy <br />C3 7. FEDERAL AGENCY <br />:-- <br />AR EQUAL-1-TION.0 ST,-.STOPGE FEE-ACCOUNTU-NUMBER <br />-A <br />z, <br />TY (TK) HO 4 <br />Call (916) 322-9669 if questions arise <br />421 <br />P Rb -91JXUS�T.- 9N 113111V <br />FINANCIAL �.-RESP S <br />INDICATE MMOO(S) 0 1. SELF-INSURED 04. SURETY BOND 117. SATE FUND <br />11 10. LOCAL GOVT MECHANISM <br />VEl 05. LETTER OF CREDIT 11 a. STATE FUND & CFO LETTER <br />3 '.GNU=E 0 6. EXEMPTION 0 9. STATE FUND &CD, <br />0 91 OTHER. <br />4Z2 <br />-n <br />YI L'WICA. <br />OTIF ON AND MAILiNGADDRESS <br />Check one box to indicate which address OxxM be used for Legal notifications end mailing. ❑ <br />Legal notAtcations maiiiings will be sent to to tank owner bless box I or 2 is chackod. 1. FACAM ❑ 2. PROPERTY OWNER 03. TANK OWNER <br />423 <br />. ...... ....... . .... .. <br />........... . ...... . . <br />VII NTSIGNATURE <br />Certification: I certify that the Womation Provided herein is true and somrate to v* best d my hw~ge. <br />SIGNATURE OF APPLIICANT/ DATE 424 <br />YPHO <br />425 <br />NAME OF APPLICANT (pint)``426 *-TQLE OF Al� <br />N ne"RAA nnrl ori kitri vY ►J"A <br />427 <br />UPCF (11`99 revised) 5 Formerly SWRC13 Form A <br />